
Bonk . U< 3 

(V^rifoN MM 

COPYRIGHT DEPOSIT. 



DISEASES 



OF 



THE STOMACH 



A TEXT-BOOK FOR PRACTITIONERS 
AXD STUDENTS 



BY 

MAX EINHORN, M. D. 

PROFESSOR OF CLINICAL MEDICINE AT THE NEW YORK POST-GRADUATE MEDICAL 
SCHOOL AND HOSPITAL: VISITING PHYSICIAN TO THE GERMAN HOSPITAL 



aftttb 1Re\MseD Edition 



NEW YORK 
WILLIAM WOOD AXD COMPANY 

MDCCCCXI 






Copyright, 1911 
By WILLIAM WOOD AND COMPANY 









Printed by 

The Maple Press 

York, Pa. 



©CI.A297487 



TO MY FRIEND AND TEACHER 

C. A. EWALD, M. D. 

PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF BERLIN 

THIS BOOK IS RESPECTFULLY DEDICATED 



PREFACE TO THE FIFTH EDITION. 



While the plan of the book has remained the same, the text 
has been thoroughly revised and several additions made. 
Radiography has made rapid strides and has contributed largely 
toward clearing the field of diagnosis. It has accordingly been 
given a more prominent place. It gives me great pleasure to 
notice the widespread interest the American medical profession 
is of late years taking in the Diseases of the digestive tract. 
That my work has been a contributing factor thereto and of 
some assistance to my worthy Colleagues affords me great 
satisfaction. 

Max Einhorn. 

New York, June 10th, 1911. 



PREFACE TO THE FIRST EDITION. 



During the last twenty years our views in the field of diseases 
of the stomach have undergone great changes. W. Beaumont 
in this country laid the corner-stone of scientific research and 
experimental study on the functions of this organ in 1825. 
From that time on the science of gastric diseases remained in 
a state of quiescence until 1867, when Kussmaul methodically 
applied the stomach pump in the treatment of dilatation of the 
stomach. The real progress, however, began a few years later, 
when Leube made use of the stomach pump for diagnostic 
purposes. Ewald, Boas, Reichmann, Riegel, and others then 
instituted extensive studies of the gastric functions in health 
and disease. This second epoch in the study of digestive 
diseases, which had its inception in Germany, soon made itself 
felt in other countries, notably France, Russia, Austria, Eng- 
land and America. In our country especially it seems that a 
very fruitful activity is developing in this direction. Among 
the older writers I would mention the names of Austin Flint, 
Delafield, Pepper, and Osier, all of whom contributed largely 
to our clinical knowledge in this branch of medicine. The 
newer researches were taken up here and further advanced by 
Charles G. Stockton, Francis P. Kinnicutt, Allen A. Jones, D. 
D. Stewart, J. C. Hemmeter, and many other very active 
investigators. The progress achieved relates to a more pro- 
found knowledge of gastric affections — by examination of the 
functions — and to a more successful therapy, first by diet, 
secondly by the newer mechanical means of treatment (lavage, 
spray, electricity), and thirdly by surgical orocedures. Our 

vii 



Viil PREFACE. 

more extensive knowledge of diet and treatment is of advantage 
not only to the specialist, but to the general practitioner as 
well, and it is with the view of assisting the latter in the acquisi- 
tion of all these advantages which have accrued that this treatise 
has been written. A series of articles on Diseases of the 
Stomach, which I contributed to the "Twentieth Century- 
Practice of Medicine" has greatly facilitated my work. In 
this book the subject has been considered from a more practical 
standpoint, and special attention has been paid to diet and 
treatment. I trust that this work will aid in awakening a 
deeper interest in the study of diseases of the stomach among 
American physicians, and if this object be realized, I shall feel 
more than recompensed for the time spent in its preparation^ 

Max Einhorn. 
New York, June loth, 1896. 



CONTENTS. 

CHAPTER I. 
Anatomy and Physiology. 

Anatomy, 1 

Situation, 2 

Blood-vessels, 2 

Relations of the Stomach to Xeighboring Organs, 3 

Structure of the Stomach, 3 

Blood-vessels, Lymphatics, and Nerves of the Stomach, 6 

Physiology 7 

The Gastric Juice, 9 

Gastric Digestion, 11 

Intestinal Digestion, 14 

CHAPTER II. 
Methods of Examination. 

Interrogation of the Patient, 17 

Methods of Physical Examination, 20 

Inspection, 20 

Palpation, 22 

Percussion, 24 

Auscultatory Percussion, 26 

Sounds of the Stomach, 26 

Splashing Sound (Clapotage), 26 

Deglutition Sounds, 27 

Dripping Sounds, 28 

Bubbling Sounds, 28 

Succussion Sounds, 28 

Gurgling Sounds, 29 

Respiratory Sounds, 29 

Sizzling Sounds, 29 

Ringing Sound- 30 

<TNopha£oscopy, 30 

Ga-troscopy, 33 

Ga-trodiaphany or Transillumination of the Stomach, 36 

Roentgen Rays 40 

Radium Transillumination of the Stomach, 48 

ix 



i CONTENTS. 

Radium Photographs of the Stomach 50 

Examination of the Functions of the Stomach 53 

Secretory Function 53 

Leube-Reigel's Test Dinner, 55 

Test Breakfast of Ewald and Boas 56 

Germain See's Test Meal, 56 

Klemperer's Test Meal 57 

Ewald-Boas' Expression Method, 58 

Examination of the Ingesta, 59 

Contraindications to the Use of the Stomach Tube, 78 

Other Methods of Testing the Gastric Secretion, 78 

Exact Determination of the Quantity of Chyme within the 

Stomach 89 

Abnormal Constituents of the Gastric Contents, 90 

Microscopical Examination of the Gastric Contents, 97 

Value and Limitations of Examinations of the Gastric 

Contents 113 

Absorptive Function of the Stomach, 115 

Motor Function of the Stomach, 116 

Mechanical Function, 119 

CHAPTER III. 
Diet. 

Dietetics, 127 

Composition of the Most Common Food Substances, 129 

Animal Foods 133 

.Me Foods, 135 

Liquid Foods, 136 

Utilization of Food, 137 

Diet in Health 137 

A Few Hints with Regard to the Proper Way of Eating, 137 

Dietetics in Diseases of the Stomach, 139 

In Acute Diseases of the Stomach 143 

In Chronic Affections of the Stomach, 145 



CHAPTER IV. 

Local Treatment of the Stomach. 

Lavage 155 

The Gastric Douche 160 

The Gastric Spray 164 

The Stomach Powder Blower , 166 

Electricity 168 

[n8tniments, Apparatus, and Chemicals Required, 180 



COXTEXTS. xi 

CHAPTER V. 

Organic Diseases with Constant Lesions. 

The Acute and Chronic Gastric Catarrh 182 

Acute Gastritis 182 

Synonyms 182 

Definition 182 

Gastritis Acuta Simplex or Acute Gastric Catarrh 1S2 

Etiology, 1S2 

Morbid Anatomy 183 

Symptomatology 1S4 

Diagnosis 1S5 

Prognosis 1S6 

Treatment 1S6 

Gastritis Phlegmonosa 1S7 

Synonyms 187 

Morbid Anatomy 188 

Symptomatology 188 

Diagnosis 1S9 

Treatment 1S9 

Gastritis Toxica 189 

Symptomatology 189 

Diagnosis 190 

Prognosis 190 

Treatment 190 

Chronic Gastric Catarrh — Gastritis Glandularis Chronica 191 

Definition 191 

Pathological Anatomy 191 

Etiology 194 

Symptomatology. 195 

Course 200 

Diagnosis 200 

Differential Diagnosis 200 

Procrno^is 201 

Treatment, .' . 202 

CHAPTER VI. 
Organic Disease^ with Constant Lesions — Continued. 

Ulcer of the Stomach 212 

Synonyms 212 

Definition 212 

Etiology 212 

Morbid Anatomy 220 

- ■ latioo of the Ulcer 224 

- :iptomatology 226 



arii CONTENTS. 

Ulcer of the Stomach, Duration of the Disease, 234 

Complications, 234 

Perforation, 234 

Diagnosis 239 

Differential Diagnosis, 240 

Localization of the Ulcer, 242 

Prognosis, 244 

Treatment, 245 

Diet in Gastric Ulcer, 247 

Exulceratio Simplex (Dieulafoy), 258 

Definition, 259 

Morbid Anatomy, 259 

Etiology, 260 

Symptomatology, 260 

Diagnosis, 260 

Prognosis, 261 

Treatment, 261 

Surgical Procedures, 262 

CHAPTER VII. 

Organic Diseases with Constant Lesions — Continued. 

Erosions of the Stomach, 267 

Definition, 267 

General Remarks, 267 

Etiology, 268 

Symptomatology, 268 

Course, 271 

Diagnosis, 273 

Treatment, 273 

CHAPTER VIII. 

Organic Diseases with Constant Lesions — Continued. 

Cancer' of the Stomach (Carcinoma Ventriculi), 276 

Definition, 276 

Etiology, 276 

Parasitic Theory, 281 

Morbid Anatomy, 281 

Topographical Relations, 284 

The Shape of the Stomach, 285 

Secondary Changes Accompanying Cancer of the Stomach, . . . 286 

Cancerous Metastases, 286 

Symptomatology, 287 

Diagnosis, 302 

Differential Diagnosis, 306 

Duration and Prognosis, 309 



CONTEXTS. xiii 

Cancer of the Stomach. Treatment 309 

Surgical 309 

Medical. 312 

Radium, 312 

CHAPTER IX. 

Functional Diseases with Variable Lesions 
Hypersecretion*. 

Hyperchlorhydria 320 

Synonyms, 320 

Definition 320 

General Remarks ' 320 

Etiology, 322 

Symptomatology 322 

Course, 324 

Prognosis, 326 

Diagnosis, 326 

Differential Diagnosis, 327 

Treatment, 327 

Gastrosuccorrhcea Continua Periodica, 331 

Synonyms, 331 

Definition 332 

General Remarks, 332 

Symptomatology 332 

Diagnosis, 336 

Prognosis 336 

Treatment 336 

Gastrosuccorrhoea Continua Chronica, 337 

Synonyms, 337 

Definition, .337 

General Remarks, 338 

Etiology, 339 

Symptomatology, 339 

Diagnosis, 340 

Differential Diagnosis, 341 

Prognosis, 344 

Treatment, 345 

CHAPTER X. 
Functional Diseases with Variable Lesions — Continued. 

Achylia Gastrica, 348 

Synonym- 348 

Definition, 348 

General Remarks, 348 

Morbid Anatomy 350 



xiv CONTENTS. 

Achylia Gastrica, Etiology, 351 

Symptomatology, 352 

Course 358 

Diagnosis, < 359 

Prognosis, 359 

Treatment, 359 

CHAPTER XI. 
Functional Diseases with Variable Lesions — Continued. 

Ischochymia, 362 

Synonyms, 362 

Definition, 362 

General Remarks, 362 

Symptomatology, 364 

Etiology, 366 

Course, 366 

Diagnosis, 378 

Treatment, 382 

Complications, 394 

Tetany, 394 

CHAPTER XII. 

Abnormal Conditions with Reference to the Size, Shape and Position 

of the Stomach. 

Abnormalities in the Size of the Stomach, 400 

Abnormalities in the Shape of the Stomach, 401 

Abnormalities in the Position of the Stomach, 401 

Enteroptosis, or Glenard's Disease, 402 

Definition, 402 

General Remarks, 402 

Etiology, 403 

Symptomatology, 405 

Diagnosis, 410 

Prognosis, 411 

Treatment, 412 

CHAPTER XIII. 

Nervous Affections of the Stomach. 

General Remarks, 420 

Sensory Gastric Neuroses, 421 

(a) Abnormal Sensations of a General Character, 422 

Bulimia, 423 

Symptomatology, 423 

Treatment, 424 



CONTENTS. xv 

Parorexia (Perversion of Appetite), 425 

Polyphagia, 426 

Akoria, 426 

Nervous Anorexia, 426 

Symptomatology, 427 

Diagnosis, 428 

Treatment, 428 

Sitophobia, 430 

Inanition, 431 

Treatment, 434 

(6) Special Sensations within the Stomach Itself, 436 

Gastric Idiosyncrasies, : 437 

Abnormal Sensations, 439 

Hyperesthesia of the Stomach 439 

Symptomatology, 440 

Diagnosis, 440 

Treatment, 441 

Gastralgia, 442 

Synonyms, 442 

Symptomatology, 442 

Etiology, • 443 

Diagnosis, 446 

Treatment, 449 

Gastralgokenosis, 450 

Motor Neuroses, 450 

Spasm of the Cardia (Cardiospasmus), 450 

Symptomatology, 451 

Diagnosis, 457 

Prognosis, 458 

Treatment, 458 

Eructation, 466 

Etiology, 468 

Treatment, 468 

Pyrosis, 468 

Regurgitation, 468 

Etiology, 470 

Prognosis, 470 

Treatment, 470 

Rumination, 470 

Synonyms, 470 

Etiology, ' 471 

Duration, 472 

Treatment, 476 

Nervous Vomiting (Vomitus Nervosus), 477 

Diagnosis, 478 

Juvenile Vomiting, . 479 

Periodic Vomiting, 479 



xvi CONTENTS. 

Reflex Vomiting 481 

Idiopathic Nervous Vomiting, 482 

Treatment 482 

Pneumatosis, 483 

Diagnosis, 483 

Treatment 483 

Hypanakinesis Ventriculi 484 

Hyperanakinesis Ventriculi, 484 

Peristaltic Restlessness of the Stomach, 484 

Treatment 485 

Antiperistaltic Restlessness of the Stomach, 486 

Incontinentia Pylori (Incontinence of the Pylorus), 486 

Pylorospasmus, 488 

Atony of the Stomach 492 

Synonyms, 492 

Symptomatology, 492 

Diagnosis, 492 

Prognosis, 493 

Treatment, 493 

Secretory Neuroses, 494 

Nervous Dyspepsia 495 

Etiology, 496 

Symptomatology, 496 

Prognosis, 498 

Diagnosis, 498 

Differential Diagnosis, 499 

Treatment, 500 

CHAPTER XIV. 

The Condition of the Stomach in Diseases of Other Organs. 

Tuberculosis of the Lungs, 502 

Syphilis of the Stomach 505 

Chlorosis and Anaemia, 509 

Heart Lesions, 509 

Dyspeptic Asthma, 510 

Disturbances of the Liver, 513 

Diseases of the Kidney, 513 

Diabetes, 514 

Arthritis Deformans, 514 

Gout, 514 

Malaria, 514 

Diseases of the Skin, 515 

Pemphigus of the Mouth, 515 

Urticaria and Erythema, 515 

Eczema, 516 

Acne Simplex and Acne Rosacea, 516 

Psoriasis, 516 



DISEASES OF THE STOMACH. 



CHAPTER I. 
ANATOMY AND PHYSIOLOGY. 

Anatomy. 

The stomach is a pyriform sac the longitudinal diameter of 
which is as a rule oblique in position. The larger part of the 
ors;an is situated higher up and more to the left than the smaller, 




Fta. 1. — The Stomach. C, cardia; P, pylorus; F, fundus; G, greater curvature; 
L, lesser curvature. 

which is directed to the right somewhat upward and sometimes 
backward. This smaller extremity terminates in the small 
intestine. The point at which the stomach communicates 

1 



2 DISEASES OF THE STOMACH. 

with the small intestine is called pylorus (P) and is recognizable 
on its outer surface by a furrow and on its inner surface by a 
protruding fold (valvula pylori). The communication between 
the (esophagus and the stomach is called the cardia (C) and is- 
situated at the upper part. A straight line (AB) drawn in 
the direction of the oesophagus and prolonged through' the 
stomach would cut off one-fourth or one-fifth of this organ to 
the left. This portion to the left is called the greater cul-de-sac 
(saccus csecus) (F) or fundus. The volume of the stomach 
varies according to the condition of its contents. When filled 
its long diameter measures 26 to 31 cm., the transverse di- 
ameter being 8 to 10 cm. at the fundus and much less at the 
pylorus. Here it measures about 2.6 cm. When the stomach 
is filled the anterior wall turns somewhat upward and the 
posterior downward (a rotation of the organ takes place). 

Situation. 

The stomach lies on the left side of the body, and only one- 
sixth of it is situated on the right side. This includes the- 
pylorus and the adjacent parts which lie behind the liver 
(lobus Spigelii) . The cardia is situated in the left parasternal 
line, somewhat above the ensiform process; the lesser curvature 
lies on the left side, close to the vertebral column and runs 
downward and parallel with it. The greater curvature ex- 
tends from the base of the gall bladder and the liver into the 
left hypochondriac region in which the whole of the fundus is 
found. 

Blood-Vessels. 

The blood-vessels enter the stomach at its upper and lower 
borders and thus divide the surface of the stomach into two 
equal parts. These lines mark the superior and inferior margins 
of the stomach, the upper and lower curvature, or the lesser and 
greater curvature. 



STRUCTURE OF THE STOMACH. 3 

The Relations of the Stomach to Neighboring Organs. 

The left segment of the stomach is in contact with the dia- 
phragm above, and to the left with the spleen and the left 
kidney. The lesser curvature and the adjacent part of the 
organ are in relation with the pancreas, and the splenic artery 
and vein. The greater curvature and a portion of the front 
wall as well as the pylorus touch the liver and also the trans- 
verse colon. 

Structure of the Stomach. 

The stomach has four coats, the serous, muscular, areolar or 
submucous, and mucous. The serous coat is derived from the 
peritoneum and forms a thin, smooth, transparent and elastic 
membrane. It closely covers the entire viscus excepting along 
it> two curvatures. Here the attachment is looser, leaving 
space for the larger blood-vessels. 

The muscular coat is composed of plain muscular tissue, 
forming three sets of fibres disposed in layers — namely, the 
longitudinal, the circular, and oblique fibres. The outermost 
layer is the longitudinal one, then follows the circular, and the 
innermost is the oblique. The latter is very incomplete, and 
is a continuation of the circular fibres of the gullet. These 
fibres descend obliquely from the cardiac orifice upon the an- 
terior and posterior surfaces of the stomach, and after spread- 
ing out from one another, they run in the direction of the 
circular fibres and terminate at the greater curvature. 

The submucous coat connects the muscular and mucous 
coats and consists of areolar tissue. It is the seat of division 
and passage of the blood-vessels. 

The mucous membrane is a smooth, soft, rather pulpy 
membrane which has a somewhat pink hue. It is .thickest in 
the pyloric region and thinnest at the fundus. 



DISEASES OF THE STOMACH. 



The mucous membrane constitutes the glandular layer of 
the organ. The glands, which number about five millions, are 
t ubular in form and are arranged perpendicularly to the surface; 
at their base and around them are fibrous tissue and lymphoid 
cells; also a thin layer of muscles (muscularis mucosae). 





Fig. 2. Fig. 3. 

Fig. 2. — A Vertical Section of the Stomach, a, Mucosa; b, submucosa; c, d, muscularis; 

e, serosa. X60. 
Fig. 3. — A Cardiac Gland, a, Parietal cells; 6, principal cells. 

The glands are composed of the following parts: 
(1) The mouth; (2) the neck, which is the thinnest part; 
(3) the body, which is much thicker, and (4) the base. 

Several tubules (two to five) very frequently end in one 
mouth. The dots that are seen on the surface of the mucosa 
consist of the openings of the glands. The whole inner surface 



STRUCTURE OF THE STOMACH. 



of the stomach is covered by columnar epithelium, which ex- 
tends for a variable distance into the mouths of the glands. 
The glands are divided into two kinds : 

1. Cardiac or fundus glands. These fill the greater part of 
the stomach and are characterized by the two following features: 
The mouth of the gland is short as 

compared with the length of the gland 
itself. They contain parietal or oxyn- 
tic cells, which are closely arranged in 
the neck of the glands. They are 
recognizable by being of a more or less 
cuboid shape and having a dark gran- 
ular appearance. They are stained 
quite deeply with the aniline dyes. 
The other cells of the glands are 
called the principal cells, and are some- 
what smaller in shape and not so dark 
as the parietal cells. 

2. The pyloric glands. The mouth 
of the gland is quite long as com- 
pared with the tube itself. The body 
of the gland consists almost entirely of 
the principal cells. Xo parietal cells 
are to be found here, although some 
cells also occur which become darkly stained with osmic acid. 
Nussbaum considered them similar to the parietal cells of the 
cardiac glands. They are usually called the Nussbaum cells. 

Besides these specific glands there are a number of mucous 
glands in the neighborhood of the pylorus. 

Heidenhain, 1 Kupffer, 2 Sachs. 3 and Stoehr 4 have greatly con- 

1 Heidenhain: Archiv fur mikrosk. Anat., vol. 6, 1870. 

2 Kupffer: "Epithel und Drusen des menschlichen Magens," Miinchen, 
1883. 

3 Sachs: Archiv f. exoerimentelle Patholog., vols. 22 and 24. 
* Stoehr: Archiv f. mLcrosk. Anat., vol. 20. 




Fig. 4.— A Pyloric Gland, a 
Mouth; b, neck; c, fundus. 



6 DISEASES OF THE STOMACH. 

tributed to our knowledge of the histology of the gastric mucosa. 
According to these writers, the principal cells generate the 
pepsin and the rennet ferments, whereas the parietal or oxyntic 
cells are imbued with the faculty of secreting hydrochloric acid. 

Blood-Vessels, Lymphatics, and Nerves of the Stomach. 

The arteries of the stomach originate from the cceliac axis, 
the left coronary artery being a direct branch of this vessel, 
and the right a branch of the hepatic artery. These supply 
the smaller curvature and form the superior ventricular arch. 
The greater curvature is supplied by the right inferior coronary 
artery, being a branch of the hepatic artery, and by the left 
inferior coronary artery, which is a branch of the splenic artery; 
they both form the inferior ventricular arch. All these vessels 
reach the stomach between the folds of the peritoneum. After 
ramifying between the several coats and supplying them with 
blood (especially giving off a number of capillaries to the mus- 
cular coat), and after dividing into very small vessels in the 
submucous areolar tunic, their ultimate arterial branches enter 
the mucous membrane and ramifying freely pass between the 
tubuli, where they form a plexus of fine capillaries upon the 
walls of the tubules and also around the mouths of the glands. 

The veins arise from the capillary network and pursue an 
almost straight course through the mucous membrane between 
the glands. After piercing the muscularis mucosae and forming 
a wide plexus in the submucous tissue, they return the residual 
blood into the splenic and superior mesenteric veins and also 
directly into the portal vein. 

The lymphatics of the gastric mucosa extend, as first shown 
by Loven, directly to the surface of the mucosa. They form 
a dense network of lacunar spaces situated between and among 
the gland tubuli, which, as well as the blood-vessels in many 
parts, they enclose with sinus-like dilatations. Near the sur- 



PHYSIOLOGY. 7 

face of the membrane, the lymph is collected into vessels 
which form loops or possess dilated extremities. These vessels 
are less superficial than the blood capillaries, although the lac- 
unar spaces extend as far as the basement membrane of the 
surface. 

The nerves originate from the abdominal part of the vagus, 
forming the interior gastric plexus at the cardia. The vagus 
here extends over the whole anterior surface of the fundus. 
The right branch of the vagus supplies with only one-third of 
its fibres the stomach wall, especially the posterior wall, 
whereas two-thirds supply the other abdominal organs. The 
branches of the sympathetic nerve coming from the cceliac 
plexus enter into many ramifications with the vagus. These 
nerves, with a number of small ganglia, form a network in the 
submucosa. 

Physiology. 

The stomach forms a part of the digestive tract, and in order 
to understand its functions thoroughly, it will be best to give 
a short review of the entire process of digestion. By the term 
11 digestion" are understood all processes which serve to con- 
vert the various food-stuffs into such a condition that they 
become fit for entrance into the circulation. These changes 
are effected by means of ferments, which replace the Bunsen 
flame of the chemist in the laboratory of the living organism. 
The ferments are produced by living cells, and possess certain 
properties in the way of effecting chemical changes when in 
contact with certain substances. All these changes can ulti- 
mately be explained as an hydration of anhydrides — i.e., the 
substances developed by their presence contain more water 
than the primary substances. 

All ferments possess the six following qualities: 

1. They are of organic nature. 



8 DISEASES OF THE STOMACH. 

2. They act only in the presence of water. 

3. The total amount of the formed products contains more 
hydrogen and oxygen (in the relation of water) than the original 
substance. 

4. They decompose peroxide of hydrogen. 

5. They act best at temperatures varying between 30° and 
60° C. 

6. Each ferment possesses a specific action, and one and the 
same substance may develop different products when in con- 
tact with different ferments. 

The ferments are divided into two classes: 

1. Formed ferments; those whose active principle cannot 
be separated from the original cell in which they are generated 
and is dependent on the life of their mother substance (yeast 
cells). 

2. Unformed ferments: those which can be separated from 
their original soil without losing their specific action. 

Most of the ferments that exist in the living organism are 
unformed (ptyalin, pepsin, rennet, trypsin, etc.). Thus far 
all attempts to isolate ferments in a chemically pure state have 
been unsuccessful. We only know that they are organic bodies 
whose structure is similar to that of the proteids. 

In the mouth the food first comes in contact with the saliva 
by the act of chewing. This secretion consists of the products 
of the salivary and mucous glands of the mouth. It is of alka- 
line reaction, low specific gravity (1.002-1.009), contains 
epithelia, mucus, ptyalin, albumin, and some salts. It also 
contains traces of potassium thiocyanate (CNKS). After being 
lubricated by the saliva, the food passes through the pharynx 
and oesophagus into the stomach. The ptyalin, which is 
characterized by converting starch into maltose or sugar, begins 
its action upon the food already in the mouth, but the principal 
work is done during the first period of digestion within the 
stomach. 



THE GASTRIC JUICE. 9 

The Gastric Juice. 

Spallanzard 1 and Reaumur were the first to make experi- 
mental studies upon the gastric juice. They recognized its 
property of digesting meat and of exerting an antifermentative 
action. Prout in 1S24 discovered hydro chloric acid in the gas- 
tric juice. These experiments have been greatly furthered 
and advanced in this country by Beaumont, 2 who at about 
the same time made a series of investigations upon the well- 
known Canadian, St. Martin, with his gastric fistula. Many 
of the facts discovered by Beaumont form the basis of our 
knowledge of the physiology of the stomach; as, for instance, 
his observations on the movements of the stomach. Blondlot 3 
first established a gastric fistula in animals for experimental 
purposes. Bidder and Schmidt 4 have conclusively shown 
that the acid of the gastric juice is hydrochloric acid, while 
Schwann in 1836 discovered the pepsin ferment. The nature 
of the acid of the gastric juice has been the subject of much 
controversy even during late years. Thus Winter and Hay em 5 
disputed the formation of hydrochloric acid within the gastric 
glands. They assert that while the glands produce an organic 
acid, this is changed into an inorganic by the presence of salt 
(sodium chloride) within the stomach. This theory, however, 
is incorrect, as it is well known that the stomach will furnish 
a secretion containing free hydrochloric acid even when no 
food or other substance containing sodium chloride has been 
ingested. 

The gastric juice is a clear, colorless fluid of an acid reaction 
and a specific gravity of 1.002-1.003. The quantity secreted 

S -illanzani: " Yersuche fiber das Vordauungsgo<chaft." Abhandlung vi. 

2 Beaumont: '"Experiments and Observations of the Gastric Juice and 
the Physiology of Digestion,'' Combe's edition, 1833. 

3 Blondlot: "Traite analytique de la digestion," Paris, 1843. 

4 Schmidt: Liebig's Annalen. xeii.. 1854. 

-Winter and Hayem: "Du Chimisme Stomachale," Paris, 1891. 



10 DISEASES OF THE STOMACH. 

in twenty-four hours is not exactly known. It is estimated 
by some to be about three pints. The principal constituents 
of the gastric juice are: (1) Hydrochloric acid; (2) pepsin; (3) 
rennet. These two ferments Pawlow and Sawjalow 1 consider 
as identical. Recently a fat-splitting ferment has been dis- 
covered in the gastric juice by Volhard. 2 

The degree of acidity varies from 0.1 to 0.2 per cent. Both 
ferments, pepsin and rennet, when first secreted are inactive 
bodies and called respectively pepsinogen and rennet-zymogen, 
but coming in contact with the acid become converted into 
active pepsin and rennet. Besides these three substances, 
the gastric juice contains water, inorganic salts, and some 
proteid matters. 

The greatest difficulty in explaining the production of gastric 
juice was encountered in the circumstance that an inorganic 
acid should be secreted by the blood, which is a strongly alka- 
line solution. Maly, 3 however, gave the following explanation: 
Some liquids with alkaline reaction may contain acid salts; 
thus in the blood there exist disodic orthophosphate and mono- 
sodic orthophosphate (Na 2 HP0 4 and NaH 2 P0 4 ), together with 
distinctly alkaline salts. AVhen such a solution is placed into 
a dialyzer immersed in distilled water the acid principle passes 
into the latter. Thus within the dialyzer there is an alkaline 
and outside an acid liquid. Maly compares the stomach and 
the kidneys to a dialyzer, and explains in this way the secretion 
of acid fluids from the kidneys and from the stomach. The 
details of the formation of hydrochloric acid may be given as 
follows : If Na 2 HP0 4 is brought together with calcium chloride 
(CaCl 2 ), there is formed triphosphate of calcium, sodium chloride, 

1 W. Sawjalow: " Zur Frage nach der Identitat von Pepsin und Chymosin." 
Z< itschr. f. phys. Chemie, Bd. 46, p. 307. 

2 Franz Volhard: "Ueber das fettspaltende Ferment des Magens." 
Zeitschr. f. klin. Med., Bd. 43, Heft 5 und 6. 

3 Maly: " Untersuchungen uber die Mittel zur Saurebildung im Organ- 
ismus." Zeitschrift fur physiologische Chemie, i., p. 174. 



GASTRIC DIGESTION. 11 

and free hydrochloric acid according to the following formula: 
2Na 2 HP0 4 +3Caa 2 =Ca 3 (P0 4 ) 2 H-4NaCl+2HCl. 

Tins theory, although very ingenious, does not suffice to 
explain the entire process of gastric secretion. For there is no 
reason why the hydrochloric acid should not be secreted in 
other organs than the stomach, the blood coming into contact 
with many other glandular apparatuses. Besides, this theory 
does not explain why the secretion should not go on all the 
time in the stomach. Here as elsewhere we are forced to accept 
a specific action of the cells which cannot be explained by 
simply physical or chemical laws. We know that there are 
cells imbued with certain specific actions that are unexplainable 
by chemical formulae. 

Gastric Digestion. 

The principal part played by gastric digestion consists in 
the conversion of albuminates (including also connective tissue 
and in a considerably minor degree nuclei) into the more 
soluble forms of propeptones and peptones, which are the 
result of the combined action of hydrochloric acid and pepsin. 
The rennet ferment curdles milk. The gastric juice is also 
endowed with the property of converting cane sugar into grape 
sugar, and gelatin into a soluble form (a peptone) which no 
longer coagulates. Besides this, a small percentage of fat is 
split into fatty acids. 

The secretion of gastric juice, according to Pawlow, 1 is under 
control of the nervous system, the secretory fibres being con- 
tained in the vagus. The act of eating (even when the food 
does not reach the stomach) produces a flow of gastric juice, 
provided the vagus is intact. If the latter is cut, then the 
mere act of eating remains without result. This proves that 
the sensations of taste, odor, etc., developed during eating, 

1 Pawlow: "The Work of the Digestive Glands,*' translated by Thompson, 

1002. 



1 2 DISEASES OF THE STOMACH. 

reflexly stimulate the secretory fibres in the vagus nerve. 
This kind of secretion Pawlow designates as " psychical." 
Gastric secretion, being thus begun, is then supplemented by 
reflex stimulations arising in the stomach itself, the mucous 
membrane of which contains, besides sensory, also secretory 
nerves. Some foods (meat extracts, meat juices, soups) are 
particularly apt to excite secretion, while others (bread, white 
of egg) are ineffective. According to Pawlow the quantity 
and quality of the secretion vary with the character of the 
food. 

Bayliss and Starling 1 have shown that the acid of the gastric 
juice, upon reaching the duodenum, produces a substance 
which is carried by the way of the blood stream to the pancreas, 
stimulating this organ to activity. This indefinite substance 
they have termed " secretin." 

Pawlow has demonstrated the existence in the duodenum 
of another important substance, namely, "enterokinase," 
which activates the trypsinogen of the pancreatic juice into 
trypsin. 

The work accomplished by the stomach in the act of digestion 
must also be ascribed to the active and passive movements 
that take place in this organ, in consequence of which certain 
physical changes are effected in the ingested food. Each 
particle of food is brought into more intimate contact with the 
stomach walls by these movements than would otherwise be 
possible. The food as a whole becomes more liquefied and 
passes, as chyme, through the pylorus into the small intestine. 
The pylorus is said to control the entrance of the more liquid 
chyme into the duodenum. It opens and closes at certain 
intervals. We are as yet not able to give a full explanation 
for this seemingly elective action of the pylorus, nor do we 
exactly know at what intervals the pylorus opens. It is only 
known that at certain times after certain meals (about two 

1 Bayliss and Starling: Journal of Physiology, 1902, p. 28, 325. 



GASTRIC DIGESTION. 13 

hours after a small meal, six to seven hours after a large meal) 
the stomach is completely empty. 

Recently Cannon 1 has made a study of the motions of the 
stomach by means of the .r-rays. He gave animals (cats) 
foods mixed with subnitrate of bismuth, exposed them to the 
Roentgen rays, and watched the action of the stomach with the 
fluoroscope. 

Movements begin a few minutes after the entrance of food 
into the stomach. Contractions start in the middle of the 
stomach and run toward the pylorus. These waves of con- 
traction appear at regular intervals. The pyloric portion be- 
comes lengthened: here the peristalic waves become more pro- 
nounced with advanced digestion. These movements serve to 
mix the food thoroughly with the gastric juice, and to reduce it 
to a thin, liquid mass — chyme. At certain intervals the pyloric 
sphincter relaxes, and the contraction wave squeezes part of 
the ehynie into the duodenum with considerable force. Differ- 
ent foods appear to leave the stomach at various periods of 
time. Thus. Cannon 2 found that carbohydrate food begins 
to pass out from the stomach soon after ingestion, and re- 
quires only about one-half as much time as the proteids for 
complete gastric digestion. Fats remain long in the stomach 
when taken alone, and when combined with other food-stuffs 
markedly delay their exit through the pylorus. It is nowadays 
presupposed that the act of closure and relaxation of the pylorus 
is controlled by chemical stimuli (hydrochloric acid, etc.). 

The stomach serves as a reservoir for the food until it is 
made fit for the passage into the small intestine, in which 
organ the main process of digestion takes place. 

Some of the substances contained in liquefied chyme are 
absorbed through the stomach wall, such as sugar, salts, pep- 
tone, perhaps propeptones; the rest passes into the small in- 

1 Cannon: American Journal of Physiology, 1808. p. 1. 359. 

2 Cannon: American Journal of Physiology. 1904. p. 12. 



14 DISEASES OF THE STOMACH. 

testine, and is subjected to the action of several secretions 
that combine there in order to further change it and make it 
fit for absorption. 

Intestinal Digestion. 

Although it is not my intention to give a detailed description 
of the process of intestinal digestion, it might still be useful 
briefly to discuss the further fate of the chyme. On the en- 
trance of the chyme into the duodenum, it is subjected to the 
influences of the bile and pancreatic juice, which are there 
poured out, and also to that of the intestinal secretion. All 
these secretions have a more or less alkaline reaction, and 
through their admixture with the chyme its acidity becomes 
less and less, until at length, at about the middle of the small 
intestine, the reaction becomes alkaline, and continues so as 
far as the ileo-csecal valve. 

Of the bile we know that it has a strongly alkaline reaction 
and that it is able to emulsify fats. It also possesses anti- 
fermentative and slightly purgative properties. 

The importance of the liver, however, cannot be judged from 
the influence which the bile exerts upon the digestive economy. 
"To regard the liver in this light," says L. Brunton, 1 "is just 
about as rational as to think that an Atlantic steamer has 
been built for the express purpose of throwing out from its. 
sides the two jets which are formed by the waste water from 
the engines. The condensed steam may be utilized and so 
may the bile, but the condensation of steam- is not the main 
object of an Atlantic steamer, nor is the secretion of bile a chief 
function of the liver." 

All the blood from the stomach and intestines must pass 
through the portal vein before it can reach the general circu- 
lation. The hepatic tissue acts the part of a prudent porter 

1 T. L. Brunton: "Disorders of Digestion," London, 1893. 



INTESTINAL DIGESTION. 15 

at a gate, and turns back or destroys dangerous intruders. 
The liver serves, briefly, the four following purposes: 

1. It is a kind of store-room of the organism, many substances 
taken up by the digestive process being kept there until their 
final use in the system. Thus many of the peptones and the 
greatest part of sugar are stored up in the liver as glycogen. 

2. It excludes from the circulation several poisonous matters 
or destroys them; curare, for instance, which is so poisonous 
when injected into the blood, proves quite innocuous when 
taken by the mouth, the reason being that the liver does not 
pass this poisonous matter into the circulation but retains it, 
and finally excretes it through the bile. The liver guards the 
organism from the entrance of many detrimental substances. 

3. It has also been proven lately that the liver is the main 
place where urea is formed. 

4. The secretion of bile. 

If now we return to the subject of intestinal digestion, we 
shall have to speak, firstly, of the pancreatic secretion, which 
is the most energetic and general in its action of all the digestive 
juices. It unites in itself the action of the saliva and the 
gastric juice besides having properties of its own. By means 
of its trypsin ferment, it converts albuminous bodies into pep- 
tones, but in a much shorter time than the gastric juice. Nuclei 
are here dissolved quicker and connective tissue much slower 
then in the stomach. If the action of the pancreatic juice 
upon albumin goes on for a longer period of time, then leucin, 
tyrosin, and several other derivatives, as asparaginic acid and 
hypoxanthin 1 are formed. Its diastatic ferment converts 
Btarch into sugar and acts in the same way as ptyalin, only 
more intensely. The third ferment it contains is steapsin, 
which emulsifies fats and tends to split them up into fatty 



8 e C. A. Ewald: "Die Lchre von der Verdaimng," p. 176, Berlin, 
1890. 



16 DISEASES OF THE STOMACH. 

ncicls and glycerin. The chemical formula for this purpose 
may be expressed as follows: 

Tristearin Steapsin Water Glycerin Stearic acid 

C 3 H a (C 17 H, 4 -COOH), + 3H 2 '" C 3 H 5 (OH) 3 + 3C 17 H 35 -COOH 

The pancreatic juice acts in an alkaline medium, and the 
chyme after its entrance into the small intestine is rendered 
alkaline by the conjoint action of the bile, the pancreatic 
juice itself, and the enteric juice. The latter, the juice secreted 
by the small intestine, is known to dissolve only fibrin, but it 
is yet uncertain whether it contains a diastatic ferment. 

The substances that have been left undigested in the stomach 
are quickly changed into soluble products in the small intestine 
(chyle) and taken up by the lymphatics and the venous blood 
current. The principal part of absorption is performed in the 
small intestine. The chyle has a slightly alkaline reaction 
until it enters the large intestine, where it again is rendered 
acid by some of the products of decomposition generated in 
the lower part of the small intestine. In their passage along 
the large intestine the undigested materials assume a more 
solid consistence in consequence of the absorption of the fluid 
portion, and become gradually changed into faeces and are 
expelled by the rectum. Several products of proteid decom- 
position are formed in the large bowel. One of these, dis- 
covered by Brieger, 1 is called skatol (C 9 H 9 N), to which the 
offensive smell of the fasces is principally due. 2 

1 Brieger: "Ueber die fliichtigen Bestandtheile der menschlichen Excre- 
mente." Journal fur prakt. Chemie, 1877. 

2 For further particulars regarding the physiology of digestion see "A 
Text Book of Physiology," by Wm. H. Howell, Philad., 1905. 



CHAPTER II. 

METHODS OF EXAMINATION. 

The Interrogation of the Patient. 

The examination of the patient begins with the narration 
of the course and symptoms of Ins trouble past and present. 
The history must state how long the trouble has existed, 
whether it began gradually or suddenly; and the supposed 
cause of the ailment. We have to inquire whether the disease 
has constantly progressed or whether it has been interrupted by 
free intermissions. We have further to inquire whether the 
symptoms have always been the same or whether they have 
changed in character since the beginning of the trouble. It is 
important to know whether there has been loss of flesh and 
whether this has been continually increasing. We should in- 
quire also as to the condition of the bowels, whether there is 
constipation or diarrhoea or both interchangeably. 

Present condition: The patient should be requested to de- 
scribe the symptoms he complains of. As this, however, is 
not done very accurately by the patient himself, we shall find 
it frequently necessary to cross-examine him. The important 
points to which attention should be directed in our cross-ex- 
amination are as follows: 

The Appetite. — Is there loss of appetite? Does the appetite 
come when the patient begins to eat? Does the appetite dis- 
appear when the patient has taken a few mouthfuls of food, 
or is there a perfect aversion for food? The loss of appetite 
ifl designated by the word "anorexia." If there is a perversion 
of appetite — that is, appetite only for unusual substances— 
we speak of " parorexia." If the appetite is increased — that 
is, if the patient becomes hungry soon after a meal — we speak 
2 17 



1 8 DISEASES OF THE STOMACH. 

of "bulimia." If the patient takes large quantities of food, 
much more than normal, but at his regular meals, we speak 
of "polyphagia." If there is no feeling of satiety no matter 
how much the patient takes, then we speak of "acoria." 

Thirst. — Inquire whether the patient becomes thirsty more 
frequently than usual or whether there is no desire whatever 
for chinks. 

Taste. — Inquire whether the taste in the mouth is all right 
or whether it is bitter, sour, or sticky, and if there is abnormal 
taste, at what time it is mostly experienced. 

Deglutition. — Does the food pass into the stomach without 
difficulty or not? If not, state whether the difficulty is ex- 
perienced only after ingestion of solid substances or also after 
fluids. 

Abnormal Sensations. — How do you feel after meals? Do 
you feel bloated? Do you experience a feeling of fulness or 
pressure in your gastric region? Do you feel sleepy or giddy, 
and if so for how long a time? 

Belching. — Do you belch much and if so, when? Does it 
occur only after a meal or also in the morning when the stomach 
is empty? Do you belch so much that it inconveniences you 
in society, or that it keeps you from your business? Is the 
belching connected with some bad smell, or is the gas that 
comes up oderless, inoffensive? 

Regurgitation. — Does the food come up into your mouth? 
If so, state whether it is sour or not, and whether this frequently 
occurs and how long after meals. If the food that comes up 
is spit out we speak of " regurgitation," but if it is chewed and 
swallowed we speak of " rumination." If only some sour 
fluid comes up, then we speak of " water brash." 

Pyrosis. — Do you experience a burning sensation at the pit 
of your stomach, and when? Is it half an hour after a meal, 
or is it three hours or so afterward? How long does this sensa- 
tion last? 



THE INTERROGATION OF THE PATIENT. 19 

Pains. — Pains when experienced at the pit of the stomach are 
called cardialgia; if in the gastric region, gastralgia. Pains are 
the most frequent complaints met with in all lands of digestive 
troubles. They may be of a severe nature so that the patient 
is obliged to stay in bed, or they may be of only a light char- 
acter so as merely to inconvenience the sufferer. When does 
the pain appeal"? Does it come right after eating or does it 
occur an horn* or two or three afterward? Does it exist when 
the stomach is empty and is it appeased by the ingestion of 
food? How long does the pain last? Does it remain all the 
time, or only a short while, or does it come and go independently 
of the food taken? If it follows the ingestion of food, is it 
more intense after partaking of certain coarse, indigestible 
aliments? Is the pain circumscribed and felt only at one spot 
or does it extend all over the gastric region? Does it radiate 
to the back and shoulder blades? Does the pain come on 
suddenly or slowly, and does it gradually increase? 

Nausea. — Is the nauseous feeling present only in the morning 
or after each meal, or does it appear after certain foods (as 
meat- ? 

Vomiting. — Inquire whether the patient vomits; if so, how 
often this occurs, whether daily or only once in two or three 
weeks. Does the vomiting occur soon after a meal or at other 
times? Does it occur in the middle of the night? Do you 
vomit large quantities? If so. of what do they consist? Is it 
only food or is it simply an acid watery fluid? Does the vom- 
ited matter contain food from previous days? Does it con- 
tain much bile? Does it smell when it is vomited or has it 
an acid, disagreeable taste? Was there ever any blood in it? 
Fresh blood looks red. while digested blood that has been in 
stomach a much longer time has a coffee-brown color. 
Is the art of vomiting connected with much exertion or does 
it take place easily? Do pains exist before vomiting and 
appear after its cessation? 



20 DISEASES OF THE STOMACH. 

Bowels.— Inquire whether the bowels move every day or not. 
Are they constipated? Is the patient always obliged to take 
some aperient and what is the nature of the aperient? Is there 
diarrhoea? State how many movements a day and the char- 
acter of the stools, whether they are very watery or whether 
there is some admixture of mucus or blood. Does the diarrhoea 
appeal* after each meal? Does it alternate with periods of 
constipation? 

Methods of Physical Examination. 

The examination of the patient should always begin with a 
thorough examination of his chest, for very often persons 
complaining of digestive troubles really suffer from diseases of 
other organs; while sometimes affections of the stomach exist 
in connection with other diseases of organic nature. After 
having ascertained the condition of the thoracic organs a special 
examination of the abdominal organs should then be instituted. 

Inspection. 

The general appearance of the patient very often affords us 
an idea of the nature of his illness, especially with regard to its 
severity, whether we have to deal with some serious trouble or 
with an affection of only a functional character. The emaciated 
and sallow look of a patient suffering from cancer and the 
well-nourished rosy face of a patient with a neurotic disturbance 
of his digestion are striking examples of what can be made out 
by a mere glance. 

We must inspect first the oral cavity and inform ourselves 
about the condition of the teeth, gums, tongue, uvula, and 
pharynx. Defective and carious teeth sometimes give origin 
to gastric disorders. 

In olden times the tongue was regarded as a mirror of the 
stomach, so that every gastric affection was judged by the 
appearance of the tongue. Although nowadays we know that 



INSPECTION. 21 

there are conditions in which the stomach is diseased and still 
the tongue has a normal appearance, and vice versa conditions 
where the stomach is in no way affected and still the tongue 
heavily coated, it is nevertheless true that many gastric affec- 
tions go hand-in-hand with changes in the appearance of the 
tongue. The tongue may at times be thickly furred or may 
appear very shiny and gray; sometimes it may show indenta- 
tions around its margin, sometimes again it may look red and 
dry like leather. 

In the pharynx we sometimes discover catarrhal conditions 
or swollen follicles. 

The uvula is sometimes very much elongated and may in 
this way give cause to some reflex digestive troubles. 

The inspection of the neck will sometimes disclose a swelling 
to the left of the larynx, which increases after partaking of 
food and may be due to a diverticulum of the oesophagus. 

The inspection of the abdomen should never be neglected. 
The contours of the stomach are at times visible in patients 
with thin abdominal walls, and especially if the stomach is 
either extraordinarily large or displaced downward. Osier 1 not 
long ago laid much stress upon this simple method of examina- 
tion, and ascertained that in many instances we can make the 
diagnosis of a dilated stomach by mere inspection. I can 
corroborate Osier's view, as I have had occasion in several 
instances of making a diagnosis of ectasia ventriculi by the 
mere visible outlines of the stomach. Tumors may some- 
times be seen and recognized as such. Their position will 
already give us a clew as to what organ they belong. By 
attentive inspection we sometimes notice peristaltic waves 
passing from left to right over a large area in the upper part of 
the abdomen, which are caused by the muscular action of the 
stomach. If these waves are intense in character and persist 

1 W. Osier: "Lectures on Diagnosis of Abdominal Tumors." New York 
Medical Journal, 1894. 



22 DISEASES OF THE STOMACH. 

for some length of time, then we have to deal with the condition 
called "peristaltic restlessness" of the stomach. Smaller 
peristaltic waves may be seen occasionally in the lower part of 
the abdomen and be due to a peristaltic movement of the 
small intestine. 

Palpation. 

Palpation is one of the best and most important methods of 
examination. A good clinician is as a rule an artist in palpa- 
tion. The best way to practise this method is as follows: 
The patient should assume an easy, comfortable, recumbent 
position; the physician stands to the right of the patient and 
places his right hand, which should not be cold, flat upon the 
abdomen. Palpation is first practised with the tips of the 
fingers without exerting much pressure. The entire abdomen 
may be examined in this manner by moving the hand from 
the left lower border of the ribs down to the left iliac region, 
going then to the right iliac region and then up to the margin of 
the ribs on the right side. If the patient contracts his abdominal 
walls too much, it is best to divert his attention from the ex- 
amination by conversing with him upon other topics. Very 
often then the abdominal walls will become more relaxed and 
palpation is rendered possible. Pay attention to any resistance 
you encounter, also the sensitiveness or tenderness of the 
different regions. By this method of light and tender palpation 
we may discover a tumor and determine its position, size, 
consistence, as well as its mobility. In examining the lower 
part of the abdomen we also palpate the inguinal region and 
ascertain whether there are swollen glands or not. 

To determine the position of the abdominal organs it is 
always advisable to make use of both hands. The left hand 
should push the organ or region to be examined toward the pal- 
pating right hand. The colon is very often felt somewhat below 



PALPATION. 23 

the navel running transversely across the abdomen as a ribbon- 
like body. The pulsating aorta, lying in the median line of 
the bod}' somewhat above the navel, is also frequently very 
clearly felt. The spleen, if enlarged or displaced, can be dis- 
tinctly explored especially during a deep inspiration, the left 
hand of the examiner pressing the left hypochondriac region 
downward and the right hand palpating just below the margin 
of the left ribs. The kidneys are accessible to palpation if 
they are displaced downward or are movable. In examining 
the right kidney the left hand of the physician is placed behind 
the right lumbar region of the patient, pressing this part some- 
what upward, while his right hand lies flat upon the right 
hypochondriac region, the patient being requested to take a 
deep breath. In examining the left kidney the position of the 
hand is reversed. The liver can be palpated when enlarged 
or when it is prolapsed. 

Palpation with Exertion of Pressure. — This can be done 
with one or two fingers. The object of this method of examina- 
tion is to test the degree of sensitiveness, tenderness, or pain- 
fulness of different regions of the abdomen. In this manner the 
circumscribed painful area of an existing ulcer may be dis- 
covered or the diffused tenderness of the whole gastric region 
that is often met with in inflammatory conditions of this organ. 
Boas 1 has devised an algesimeter for the purpose of indicating 
at what degree of pressure pain is experienced by the patient. 
It is provided with a scale giving the different pressures in 
weights; thus a pressure amounting to 5 to 10 kgm. in weight 
causes pain only in catarrhal conditions, whereas in ulcer of 
the -tomach a weight of only half a kilogram produces intense 
pain. As a rule, I think we can dispense with this instrument. 
The amount of pressure exerted and felt by the hand is thor- 
oughly sufficient to an experienced practitioner. 

1 J. Boas: "Diagnostik unci Therapie dor Magcnkrunkheiten," i., p. 75, 
Leipzig, 1894. 



24 DISEASES OF THE STOMACH. 

Percussion. 

In percussing the stomach it is best to use finger percussion 
and to practise this procedure without much force. The object 
of this method of examination is to determine if possible the 
situation of the stomach. This organ, being as a rule partly 
filled with air, gives a tympanitic sound on percussion. It is, 
however, quite difficult to ascertain its exact size, as the large 
intestine may be filled with gas and also give the same tym- 
panitic sound. For this reason Piorry 1 suggested filling the 
stomach with water before resorting to percussion. The 
stomach when filled in this manner gives a dull sound, which 
can then be more easily differentiated from the tympanitic 
sound of the colon. The best way to examine the patient, 
according to Piorry, is to let him drink large quantities of water 
(about one litre) and to examine him when standing. The 
same method was frequently used afterw r ard by Penzoldt. 2 
Dehio, 3 who is also a strong advocate of this method, gives the 
water, however, in fractional quantities. The patient first 
drinks one-fourth litre of water and is then examined; he now 
takes the same amount, after which a second examination is 
made, and so on until the whole litre of water has been ingested. 
The area of dulness that is found on the abdominal wall is marked 
each time with a lead pencil. It is necessary to note whether 
the lower limit of this area has extended considerably farther 
down after the addition of each portion of water. In dilated 
stomachs the lower limit of this area will be found quite far 
down below the navel, whereas in normal stomachs the lower 
limit will usually be above it. According to Boas 4 the Dehio 
method furnishes a test of the tonicity of the gastric muscle. 

Piorry: "Die mittelbare Percussion," Wiirzburg, 1828. 

2 Penzoldt: " Die Magenerweiterung, " Erlangen, 1877. 

3 Dehio: "Zur physikalischen Diagnostik der mechanischen Insufficienz 
des Magens." Verhandl. des VII. Congresses f. innere Medicin, 1888. 

4 J. Boas: hoc. cit., p. 85. 



PERCUSSION. 25 

Boas asserts that in all cases where the lower limit of the dull 
area descends quickly after the further addition of the water 
there exists a kind of weakness or atony of the stomach. 

As the results obtained by the above methods of percussion 
are not always sufficient and clear, several other means have 
been introduced which permit of a better recognition of the 
size of the stomach. The first, and so to speak clinical method, 
applied for this purpose is that devised by Frerichs 1 and con- 
sists in filling the stomach with carbonic-acid gas. It is done 
in the following way : The patient first takes 2 gm. of sodium 
bicarbonate in a half-glassful of water, then 2 gm. of tartaric 
acid also dissolved in the same quantity of water. The sodium 
bicarbonate coming in contact with the tartartic acid in the 
stomach gives rise to the development of carbonic-acid 
gas, which distends the organ. The contours of the stomach 
are now sometimes visible through the abdominal wall. If 
this is not the case percussion is now applied in order to map 
out the tympanitic area. This method can certainly be very 
frequently applied and will prove useful to the practitioner. 
It has, however, two disadvantages, one being that the quantity 
of gas is sometimes insufficient, and the other that it might 
be too large and give the patient a feeling of pressure in the 
stomach. In order to overcome these difficulties, Runeberg 2 
first made use of a tube and a rubber bulb attachment that 
allowed the forcing of air into the stomach. Here the quantity 
of air can be easily regulated, the stomach examined in different 
states of distention, and afterward the air removed through 
the tube. This is the method of examination most commonly 
applied and in daily use. 



'Frerichs: Cited from H. v. Ziem^son. "Klin. Vortrage," 1883, Xo. 12, 
p. 13. 

2 Runeberg: "Ueber kunstliche Aufblahung dea Afagens und dea Dick- 
darms durch Einpumpen von Luft." Deutsches Archiv f. klin. Medicin, 
vol. 34. p. 400. 



26 DISEASES OF THE STOMACH. 

Auscultatory Percussion. 

Auscultation by means of the stethoscope to the sounds pro- 
duct* el by percussion has been practised by several observers, 
and recently warmly recommended by W. Pepper. 1 The 
patient holds the bulb of the stethoscope and moves it about 
while the physician percusses and maps out the abdominal 
organs. The same method can also be executed with the 
phonendoscope. 

Sounds of the Stomach. 

1. The Splashing Sound (Clapotage). 

Whenever the stomach is filled partly with liquid and partly 
with gas it is possible to produce a splashing sound by striking 
the abdominal wall in the gastric region. This sound is dis- 
tinctly audible at a short distance from the patient. Bouchard 3 
made an extensive study of this splashing sound and considered 
it a sign of great diagnostic value in dilatation of the stomach. 
Nowadays we do not attach so much importance to the splash- 
ing sound per se. Dr. A. Rose 3 and myself have recently ex- 
amined a hundred cases for the existence of this symptom and 
found it present in many persons not troubled in any way 
with digestive disturbances. The importance of the splashing 
sound, in my opinion, is that wherever it is present or can be 
produced, it allows us to ascertain the position of the stomach. 
In dilated stomachs this sound can be produced over a very 
large area of the abdominal wall, extending sometimes far 
down to the pubes. 

1 W. Pepper: "The Diagnosis and Treatment of Dilatation of the Stom- 
ach," Medical Record, May 9th, 1896. 

2 Bouchard: Gaz. hebdomadaire de M6decine et de Chirurgie, 1884. 

3 A. Rose: "What is the Significance of the Splashing Sound of the 
Stomach." New York Medical Journal, June 15th, 1895. 



DEGLUTITION SOUNDS. 27 

Another point of importance seems to me to be the ease 
with which the splashing sound can be repeatedly produced. 
In cases of gastric dilatation and when the walls of the stomach 
are relaxed, even light tapping of the abdomen will always 
give rise to this sound. In normal conditions a splashing 
sound can sometimes be produced by striking the abdomen 
with the hand, but on repeating this procedure at once we will, 
as a rule, fail to produce it, as the stomach then contracts 
more or less, and it is necessary to wait quite a while until it 
has become relaxed before this sound can be again evoked. 

On examining the patient in the fasting condition the ex- 
istence of the splashing sound is of value in showing that the 
stomach is not empty and hence abnormal. Tins, however, 
is not a reliable sign and I perfectly agree with Debove and 
Remond 1 that sometimes, although rarely, the stomach may 
be found empty notwithstanding a splashing sound. Moreover, 
the absence of this phenomenon in the fasting condition does 
not by any means warrant the conclusion that the organ is 
empty. In many instances I was able to persuade myself that 
the stomach contained considerable quantities of food notwith- 
standing the absence of the splashing sound. 

2. Deglutition Sounds. 

The deglutition sounds were first described by Kronecker 
and Meltzcr. 2 When chinking there is at times a sound to be 
heard simultaneously with the act of deglutition which is 
termed the first deglutition sound. More frequently a second 
sound is noted about .-even -econds after the act of deglutition. 
Both sounds can be heard at the ensiform process either by 
placing the ear at that spot or by means of a stethoscope. As a 

1 Debove et Remond: "Traite des maladies de 1'e.stomac," Paris. 
- J. ftfeltzer: " Schluckger&usche im Scrobicuius Cordis und ihre 
physiologische Bedeutung." Centralbl. f. die medicin. \\ i>>cnsch., 1883, 
No. 1. 



28 DISEASES OF THE STOMACH. 

rule only the second sound is perceptible. If the first sound 
is present, the second sound may also appear or at times may 
be absent. The presence of these deglutition sounds permits 
us in some measure to judge about the permeability of the 
cardia, and their main diagnostic value consists in demon- 
strating their absence, for then we are entitled to presume 
that the ingested liquid has not reached the stomach, but has 
remained in the oesophagus above the cardia. This is most 
often the case in strictures of the cardia, although occasionally 
this condition might be caused by a deficiency in the peristaltic 
motion of the oesophagus. 

3. When the patient is drinking we can hear, by putting 
our ear to the abdominal wall corresponding to the gastric 
region, a kind of chipping sound, arising from the passing 
down of the fluid along the gastric wall. By mapping out 
exactly the spots over which the sounds can be heard while the 
patient is chinking we may at times be able to determine the 
contour and size of the stomach and form an idea whether the 
organ is enlarged or not. 

4. 0. Rosenbach 1 has suggested that the size of the stomach 
may be ascertained by giving the patient some water to drink 
and then blowing in some air by means of a stomach tube. 
As soon as the end of the tube reaches the level of the water 
and air is blown in, a bubbling sound arises, which can be 
heard by placing the ear over the corresponding part of the 
abdominal wall, and the exact site marked out. As soon as 
the end of the tube is above the level of the water one can 
hear only the air striking the stomach wall, but unaccompanied 
with the bubbling sounds. By alternately raising and lowering 
the tube the height of the level of the fluid can be approximately 
determined. 

5. The succussion sound. This sound was first described 

1 O. Rosenbach : " Der Mechanismus und die Diagnose der Mageninsuffi- 
cienz." Volkmann's "Samml. klin. Vortriige," 1878, No. 153. 



DEGLUTITION SOUNDS. 29 

and utilized for diagnostic purposes by Hippocrates. The 
method consists in shaking the patient and listening. If the 
stomach is considerably enlarged and contains liquid and gas, 
splashing sounds are produced and can be heard at quite a 
distance from the patient. Such sounds also occur under other 
circumstances if the patients change their position, for instance, 
when turning from one side to another in bed, and give rise to 
considerable annoyance. 

6. Gurgling sounds may be heard when the stomach, which 
does not contain any liquid but some air or gas, suddenly con- 
tracts. Thus every one is acquainted by personal experience 
with the sound generated in the stomach when one is very 
hungry. As the Germans say: "The stomach growls." 

7. Respiratory sounds. Sounds arising synchronously with 
inspiration. These are heard especially in cases of gastric 
dilatation or of gastroptosis. or where the stomach occupies a 
vertical position, particularly in women who wear corsets. 
The sound may assume two characters, according to its mode 
of production: One sound is produced during the act of in- 
spiration by the gliding of the abdominal wall over the stomach 
when distended with gas. It is similar to the sound that is 
produced by the cello, and may perhaps be explained by reason 
of the gas being compressed and forming a resounding surface 
which is set into vibration by the movements of the abdominal 
wall. The second sound is caused by the rise and fall of liquid 
during the act of respiration. It has a somewhat splashing 
or squirting character. These sounds are very frequently met 
with and especially heard in laches' society. 

8. Sizzling sounds. These can be heard only on direct 
auscultation, and are produced by gas forming quickly in the 
stomach. They are normally found after the introduction into 

omach of bicarbonate of soda and tartaric acid, carbonic- 
acid gas being set free and giving rise to these sounds. Patho- 
logically they are developed spontaneously and are a positive 



30 DISEASES OF THE STOMACH. 

sign of fermentation going on in the stomach and consequently 
of stagnation of food. 

9. Ringing sounds. These have been described by Laker 1 
in a case of dilatation of the stomach. They are synchronous 
with the heart sounds and can be heard at quite a distance 
from the patient. 

(ESOPHAGOSCOPY. 

(Esophagoscopy in the diseases of the oesophagus and cardia 
has gained an important place in the last few years. All the 
literature of importance on this subject will be found in an 
article 2 published by me in the year 1897, regarding the inspec- 
tion of the oesophagus and cardia. Further important papers 
on oesophagoscopy are those of Von Hacker, 3 Rosenheim/ and 
Gottstein. 5 Von Hacker's epoch-making labors show most 
clearly the high and practical value of this method of examina- 
tion, which not only facilitates the diagnosis of many of the 
diseases of the oesophagus, but frequently exerts a direct 
influence upon their treatment. 

In the instruments used up to now for oesophagoscopy 
(Mikulicz, Rosenheim, Kelling) the source of the illumination 
is outside of the oesophageal tube. As a rule, the panelectro- 
scope is employed for this purpose, an instrument that throws 
concentrated light through the whole tube, thus illuminating 

1 Laker: "Ueber ein rhytmisches Klangphanomen des Magens." Wiener 
med. Presse, 1889, Nos. 43 and 44. 

2 Max Einhorn: "The Inspection of the (Esophagus and Cardia." New- 
York Medical Journal, December 11, 1897. 

3 Von Hacker: "Die (Esophagoscopie und ihre klinische Bedeutung." 
Beitrage zur klinischen Chirurgie, Bd. 20, 1898, p. 141; "Die (Esophago- 
scopie beim Krebs der Speiserohre und des Mageneingangs," Ibid., p. 275; 
" Ueber die Entfernung von Fremdkorpern aus der Speiserohre mittelst 
der (Esophagoscopie, Ibid., Bd. 29, p. 128, 1901. 

4 Theo. Rosenheim: "Ueber OEsophagusstenose." Deutsche Klinik, 
1901. 

(ieo. Gottstein: "(Esophagoskopie," Jena, 1901. 



(ESOPHAGOSCOPY 



31 



the lowest spot that is to 
inspection would be easier if 
end of the tube near the 
area to be examined, since 
a better illumination could 
in this way be secured. 
With the appearance of 
the so-called " cold-lamps" 
this principle could be 
practically executed. 

The cesophagoscope 
which I use 1 consists, as 
the accompanying draw- 
ing (Fig. 5) illustrates, of 
a round, hollow metal tube 
having on one side a small 
longitudinal groove (B), 
which is separated by a 
thin wall from the lumen of 
the tube. Two isolated 
electric wires attached to 
a carrier (F) 2 run through 
the groove (B). At their 
end a small lamp (G) is at- 
tached and placed a little 
above the end opening 
of tube (A), being, how- 

1 Max Einhorn: "A New 
CEsophagoscope." Medical- 
Record, January 25th, 1902. 

2 The carrier can be easily 
removed with the lamp, thus 
facilitating thorough cleansing 
and sterilization of the instru- 
ment and any necessary re- 
newal of lamp. 



be inspected. It is evident that 
the lamp were placed at the lower 




Fig. 5. — The CEsopha- 
goscope: lower part 
partially removed to 
show its construc- 
tion. (-^ natural 
size.) 

A . Hollow metal 
tube. 

B. Longitu d : 
groove. 

C. Handle. 

D. Plug. 

E. Obturator. 

F. Carrier, 
wires. 

G. Lamp. 



n a 1 



with 



G 



t 



32 



DISEASES OF THE STOMACH. 



ever, not inclosed by the thin metal sheet that covers the wires. 
To the tube are attached a handle (C), a plug (D), and an 
obturator (E). 

Before introducing the instrument the obturator must be in 
place, and is held there firmly by means of the plug (D). After 
the introduction of the instrument this plug is removed and 




Fig. 6. — Showing Patient with (Esophagoscope inserted ready for inspection. 



the obturator withdrawn. The wires are connected with an 
electric battery, and everything is now ready for inspection. 
The handle (C) facilitates the use of the instrument. 

I usually practise cesophagoscopy in the sitting posture 
without any anaesthetic (cocaine spray, etc.). The procedure 
is not a difficult one, and is done as follows: 



GASTROSCOPY. 33 

Method. — The patient sits on a chair which has a back. The 
instrument (with obturator inserted) is immersed in warm 
water, and, while depressing the tongue with the left index 
finger, is held in the right hand like a pen and introduced into 
the mouth and pharynx of the patient. The latter is now 
directed to throw his head backward, and the instrument is 
then pushed down into the oesophagus without exerting any 
force. 

The accompanying drawing (Fig. 6) shows the position of the 
patient after the introduction of the instrument. Attention 
must be paid that the lips of the patient are not pressed by 
the instrument. The obturator is now removed, the connec- 
tion made, and an inspection may then take place by looking 
into the tube. At the end of this, the mucous membrane of the 
oesophagus is plainly visible. If the instrument is slowly 
withdrawn while looking into it, the whole wall of the oesopha- 
gus may thus be inspected. 

I have had the oesophagoscope 1 made in three different 
lengths (35, 40, and 44 cm.) and two thicknesses (1 and 1.5 
cm.), which will fulfil various indications. The thicker instru- 
ment will be used more especially in the local application of the 
medicaments, or for the removal of foreign bodies, whereas we 
would ordinarily get along with the more slender instrument. 

Gastroscopy. 

The object of this method of examination is to look into the 
stomach and to ascertain the condition of the gastric mucosa. 
This method was inaugurated by Mikulicz 2 in 1881. The 
gastroscope is similar in shape and construction to the cysto- 

1 A very similar instrument only much longer Chevalier Jackson uses for 
gastroscopy, the patient being under general anaesthesia. 

-'.Mikulicz: "Ueber Gastroskopie und GEsophagoskopie." Wiener med; 
Presse, 1881, No. 15. 
3 



34 



DISEASES OF THE STOMACH. 



scope, but much larger in size. 1 The gastroscopes which had 
been used thus far have a lamp at the end and an optic arrange- 



d 



B 



B 



Fig. 7. 



ment above the lamp on the side of the instruments. It is, 

1 Remark: Recently Th. Rosenheim, of Berlin, has constructed a new 
oesophagoscope and gastroscope. For details see "Ueber die Besichtigung 
der Cardia nebst Bemerkungen uber Gastroskopie." Deutsche med. Wochen- 
schr., 1895, No. 45. 



GASTROSCOPY. 35 

therefore, possible to obtain merely a lateral view of the organ, 
namely, of that piece lying opposite the window. It appeared 
to me that it would be of advantage to modify the instrument 
in such a manner that the lamp end piece could be pushed out 
of the way when inspecting. For then a view straight down 
would be possible. 1 

In December, 1901, I 2 had Wappler & Co., of New York, 
construct a gastroscope on this principle for me. The instru- 
ment consists of a hollow metallic tube at the upper part of 
winch there is an adjuster (A), and at the side of which is a 
groove (B), containing a rod with a lamp at its end (C) (lamp 
carrier). This rod can be moved up and down, and can also 
be rotated. At its upper part the rod contains an attachment 
for current connection. 

When inserting the gastroscope the lamp just closes up the 
opening of the tube and serves as an obturator. The adjusting 
piece is pushed upward and holds the lamp carrier and the tube 
together in such a manner that no change in position between 
the rod and tube is possible. When the lower part of the 
instrument has reached the stomach, the adjuster is slipped 
downward. The lamp carrier is pushed somewhat down and 
rotated to the side. In this manner the lamp is taken away 
from the lower end of the tube and the latter free for use. A 
direct view of a very minute piece of the stomach wall is now 
immediately made possible. The field of vision is considerably 
enlarged by inserting telescopes into the metal tube — one with 
a lens at its end permitting inspection of the entire area straight 
forward, the other with a side window, allowing vision of the 
side of the stomach opposite the window. 

The accompanying figure illustrates the above arrangement. 
The Electrosurgical Company of Rochester constructed a 

oer has very recently described a similar instrument in the Berliner 
klinische Wochensehrift. 

- Max Einhorn: "A New Gastroscope." Medical Record, June 11th, 1910. 



30 DISEASES OF THE STOMACH. 

similar gastroscope for me about five or six years ago. I have 
used this gastroscope on patients at my office as well as in the 
German Hospital, off and on, for several years. This method 
of examination has not, however, come into general practice; 
the chief reason being that a stiff metal tube has to be inserted 
into the stomach, which is hard to manage and causes great 
discomfort to the patient. As in all cases in which we have to 
deal with cancer or with other grave lesions of the stomach, 
there is always suspicion of an ulcer, this means of examina- 
tion is somewhat inconvenient, and also dangerous on account 
of the risk of perforation. 

Gastrodiaphany, or Transillumination of the 
Stomach. 

The method of transilluminating living tissues was first 
applied by Cazenave in 1845. Milliot 1 in 1867 tried to trans- 
illuminate the stomach of animals, and used for that purpose a 
narrow glass tube in which there were two thin platinum wires 
connected with the electrodes of a Middeldorpfs apparatus. 
In 1889 I 2 succeeded in transilluminating the stomach of human 
beings by means of a soft-rubber tube at one end of which is 
fastened an Edison lamp by means of a small metal mounting. 
From here conducting wires run to the battery. At some 
distance from the rubber tube there is a current interrupter. 
I have called this apparatus the gastrodiaphane and the method 
of transilluminating the stomach, gastrodiaphany. 

The aims of gastrodiaphany are: 1. To ascertain the exact 
position and the size of the stomach. 2. To recognize tumors 
or thickenings of the front wall of the stomach by their lack of 

1 Milliot: Schmidt's Jahrbiicher, Bd. 136, p. 143. 

''Max Einhorn: "Die Gastrodiaphanie." New Yorker med. Monats- 
schrift, November, 1889. "On Gastrodiaphany." New York Medical 
Journal, December 3d, 1892. The Journal of the American Medical Asso- 
ciation, 1893. 



GASTRODIAPHAXY. 



37 



translucency. Of late many investigators have busied them- 
selves with tins method of examination. Heryng and Reich- 
maim, 1 Ren vers, 2 Pariser, 3 Stewart, Ewald, Kuttner and 




Fig. 8. — The Gastrodiaphane (Einhorn). 



Jacobsohn, 4 Martins and Meltzing, 5 Stockton, Friedenwald, 6 
M. Manges/ and many others, and all have come to about the 
same conclusions as I have. Meltzing especially has written a 

1 Horyng und Reichmann: Therap. Monatshefte, 1892. 

2 Renvors: Ver. f. innere Medicin, April 4th, 1892. 

3 Pariser: Berl. klin. Wochenschr., 1892, Xo. 32. 

* Kuttner and Jacobsohn: Berl. klin. Wochenschr., 1893, No. 39. 

■ Meltzing: Zeitschr. f. klin. Medicin, 1895. 

•J. Friedenwald: "Electric Illumination of the Stomach." Maryland 
Med. Journ.. Jan. 20th, 1894. 

7 M. Manges: "The Value of the Modern Diagnostic Methods in Diseases 
of the Stomach. - ' Medical Record, February 2d, 1895. 



38 



DISEASES OF THE STOMACH. 



very extensive and elaborate paper on gastrodiaphany and has 
tried to determine the normal position of the stomach by 
this means. 

Method of Examination. — The patient, in a fasting condition, 
drinks one to two glassfuls of water. The apparatus, lubri- 
cated with glycerin or simply moistened in water, is then 
inserted into the stomach and connected with the battery. 
The examination is made in a perfectly dark room, either in 




Fig. 



— Transilluminated Zone of a Normal Stomach (M. S.). The dotted area in the 
centre shows the spot which was more luminous, being nearer to the lamp. 



the standing or recumbent position of the patient. The 
stomach transmits the electric light through the abdominal 
walls, and it thus becomes visible as a red zone at that place 
of the abdomen which corresponds to the position of the 
stomach. In case the gastric front wall is occupied by a 
tumor, the latter will not transmit the light and will be recog- 
nizable as a shady spot within the red zone of the transillumi- 
nated organ. 



GASTRODIAPHAXY 



39 



Kemp 1 has recently recommended to fill the stomach with a 
weak fluorescin solution before transilluminating the stomach. 
He gives the patient two glassfuls of water containing 2 gm. 
of bicarbonate of soda, 1 teaspoonful of glycerin, and 0.01- 
0.015 gm. fluorescin. 

According to my experience the addition of fluorescin does 
not in any way materially change the result of gastrodiaphany. 
The main point, in order to obtain a good outline of the 




Fig. 10 — Transilluminated Zone of a Dilated Stomach (patientWm. L\). 

stomach, is to have a strong enough light and to examine 
the patient in a dark room. Instead of the latter the patient 
may put on a long black rubber gown, on the style of a gossa- 
mer, when being gastrodiaphaned, the examining physician 
standing underneath this robe, which shuts off the light. 

The accompanying illustrations, obtained from patients 

1 R. C. Kemp: "Observations on Dilatation of the Stomach and on Gas- 
troptoais." Medical News, August 6th, 1904, p. 249. 



40 



DISEASES OF THE STOMACH. 



whoso stomachs have boon transilluminated by the gastro- 
diaphanc in different conditions, explain themselves. 

Roentgen Rays. 

Roentgenography of the Stomach. 

Rieder, 1 Holzknecht, 2 Williams, 3 and Hulst 4 have recently 
succeeded in taking good Roentgenographs of the stomach. 




Fig. 11. — Transilluminated Zone of a Dilated Stomach (patient H. O.). The dotted area 
in the centre shows the spot which was more luminous, being nearer to the lamp. 

The method consists in giving the patient, when the stomach 

'Rieder: " Beitrage zur Topographie des Magendarmkanales beim 
lebenden Menschen." Fortschritte a. d. Geb. der Roentgenstrahlen, Bd. 8, 
Heft 3, p. 141. 

2 G. Holzknecht: "Ueber die radiologische Untersuchung des Magens im 
Allgemeinen und ihre Verwerthung fur die Diagnose des beginnenden Carci- 
noms im Besonderen." Berl. klin. Woch., 1906, No. 5, p. 127. 

3 Williams: "The Roentgen Rays in Medicine and Surgery," p. 350. 

4 Henry Hulst: "Roentgenography in Diseases of the Stomach and 
Intestines." The Archives of Physiological Therapy, January, 1906. 



GASTRODIAPHANY. 



41 




Fig. 12. — Transilluminated Zone of the Stomach in Gastroptosis (from Mrs. P. F.). 




PV;. 13. — Result of Ga-tro<liaphany in a Patienl with Carcinoma of Stomach. 
area represents situation of tumor. 



Dark 



42 



DISEASES OF THE STOMACH. 




Fig. 14. — Text-book Stomach (Cole). Greater curvature just above navel; two wave type 
of peristalsis; pylorus and first portion of pylorus visible. 




Fig. 15. — Fish-hook Stomach (Rieder). No active peristalsis; greater curvature quite a 
distance below navel; the entire ring of the duodenum visible, also the first portion of the 
duodenum distended cap-shaped (Cole). 



ROEXTGEX RAYS. 



43 



is entirely or partly empty, a pint of milk into which one 
ounce of subnitrate of bismuth has been suspended by thorough 
mixing. The patient is then immediately subjected to the 
action of the x-rays, in a standing or recumbent posture. By 
holding a photographic plate directly over the abdomen the 
Roentgen picture can be obtained. The time of exposure is 




Fig. 16. — Drain trap Stomach (Crane). 

usually ten to fifteen seconds. If a fluoroscope is used instead 
of the plate, the stomach may be thus inspected. 

In conjunction with Dr. Cole I 1 have recently examined 
a considerable number of patients with the x-rays and have 
convinced myself that this method is an excellent one. It 
has the great advantage that no instruments whatever are 
introduced into the stomach, and that it permits also an 

1 Max Einhorn and Cole: Medical Record, 190G. 



14 DISEASES OF THE STOMACH. 

investigation of the colon, by exposing the patient to the 
x-rays a second time on the day following. 

As illustrations I append a few Roentgenographs obtained 
by Dr. Cole and myself. 

The bismuth method has now become the clinical method 
used by most radiologists. As we mentioned before, the 
advantage of this method lies in the fact that no instrumen- 




Fk;. 17. — Dilated and somewhat Prolapsed Stomach, Pylorus being held in Position. 

tation is required for the stomach and little instrumentation 
for the colon. A disadvantage, however, consists in having 
to administer one or two ounces of bismuth in solution, which 
is a considerable amount, and which, although very rarely, 
can develop toxic effects. Such instances of poisoning have 
been recently described in literature by quite a few authors. 
We also had occasion to observe a mild degree of poisoning 



ROENTGEN RAYS. 



45 



in one of our patients after making a radiogram with bismuth 
in the stomach. A few hours after the administration of the 
bismuth into the stomach, an acute diarrhoea developed, and 
the patient was sick for a few days, but recovered entirely 




Fig. 18. — (Patient T.) Represents a dilated and prolapsed stomach inflated with air 
which makes it appear light in the reproduction instead of dark as it would with bismuth. 
The greater curvature is easily made out. L. C. indicates the lesser curvature; E. P. indi- 
cates Einhorn's pump by means of which the air is pumped into the stomach; U, indicates 
umbilicus: P. M. indicates pyloric muscle; D, indicates first portion of the duodenum. If 
this figure is held at a distance of about three feet the stomach will be seen to better 
advantage. 



afterward. In this particular case the bismuth was admin- 
istered in a pint of rich cream. 

The bismuth method has another disadvantage, viz.: in 
making radiograms of the digestive tract we get a shadow 



46 DISEASES OF THE STOMACH. 

which occasionally may prevent one from recognizing some 
thickening which produces a shadow by itself. It appeared 
to both of us that if it were possible to make a radiogram, 
filling the organ to be radiographed with some substance easily 
penetrated by the x-ray, we would in this way be able to 
distinguish one organ from another by a greater amount of 




Fig. 19. — (Patient A.) Shows a large tumor outside of the stomach and pressing on it. 
T. indicates tumor, which is surrounded by a light area which is the stomach inflated with 
air. F. indicates fundus of stomach. S. T. indicates stomach tube. U. indicates umbilicus. 

penetration. We would, perhaps, also be able to recognize 
tumors in earlier stages than by the other methods. For 
this purpose Dr. Cole and myself 1 tried inflation with air by 
inserting a tube into the stomach or into the colon and inject- 

1 L. G. Cole and Max Einhorn: Radiograms of the Digestive Tract by 
Inflation with Air. N. Y. Medical Journal, Oct. 8th, 1910. 



ROEXTGEX RAYS. 47 

ing air with a Politzer bulb. This method of making radio- 
grams of the stomach and colon with air may not be entirely 
new. but neither of us has ever seen it described in literature 
nor radiograms illustrating it, so that if attempts have been 
made in this direction they must have been unsuccessful. We 
may be permitted to reproduce here several radiograms of the 
stomach and colon taken by this method. We also give here 
a reproduction of two cases of tumors in the gastric region. 
One of these tumors was in the spleen and pressing on the 
stomach, and the other case represents a tumor in the wall 
of the stomach which can be readily recognized by the air 
method. 

Technic. — The patient must be absolutely in the fasting 
condition, and it is best to have given a cathartic the night 
before, in order to have emptied the entire intestinal tract. 
A tube of small diameter is then inserted into the stomach, 
or one of the Einhorn duodenal pumps may be introduced, 
not allowing it to immigrate into the duodenum, and then a 
rubber bulb, holding about one ounce of air, is attached to 
either. The markers should have been placed over the umbili- 
cus and the ensiform process, and the patient placed on the 
table. Although the plates illustrating this paper are all made 
with the patient lying with the abdomen flat on the plate and 
the tube perpendicularly over the third lumbar vertebra, the 
authors believe the results would be better still if the patient 
were to lie on the back with the tube behind and the plate 
on top of the abdomen. This would allow the air to accumu- 
late at the pyloric portion of the stomach, where we are most 
anxious for the detail, and less pressure would be exerted on 
the abdomen. After everything has been adjusted and the 
vacuum of the tube regulated to the proper penetration, air 
is rapidly pumped into the stomach or colon, keeping account 
of the amount of air injected (each pressure of the bulb amounts, 
to about 30 c.c. of air). In the normal stomach about twenty 



48 DISEASES OF THE STOMACH. 

compressions of the bulb are sufficient to distend the stomach 
before the patient complains of fulness. In the colon, about 
thirty or forty compressions will suffice. The same method 
has also been applied in the oesophagus. 

One more important factor in the technic is the making 
of the radiograph immediately after the inflation of the stomach. 
The authors use an axray tube backing up a four-inch parallel 
spark when using forty or fifty milliamperes. Through such a 
tube radiograms may be made of a moderate sized patient in 
about one second. With the screen, this time may be very 
materially diminished without detracting from the detail of 
the plate. 

While the detail in these radiograms may be recognized 
near by, they are seen much more distinctly at a distance of 
thirty feet, or viewed through an opera glass in the inversed 
position. 

In looking over a collection of radiograms taken by this 
method (Figs. 14 to 19), we must say that this is a very prac- 
tical method, by means of which the size, shape, and position 
of the different organs of the digestive tract can be determined 
and tumors can also be recognized. 

We would like to remark that while this method certainly 
is not able to replace the old and well established bismuth 
method, it will find a place in conjunction with it or when the 
other cannot be applied. 

Radiumtransillumination of the Stomach. 1 

By means of 0.05 gm. of pure radium bromide it is possible 
to transilluminate the stomach. The Radiodiaphane (see Fig. 
20) and Kahlbaum's barium platino cyanide screen are best 
used for this purpose. 

'Max Einhorn; "Observation on Radium." Medical Record, July 
30th, 1904 



RADIOITRAXSILLVMIXATIOX. 



49 



Proceed as follows: 

The patient is examined on an empty stomach either before 
breakfast or seven to eight hours 
after a meal. The patient must re- 
move all clothing from thorax and 
abdomen. The radiodiaphane (con- 
taining 0.05 gm. bromide of radium 
of 1.000,000 strength in its capsule) 
is slightly moistened with water and 
introduced into the stomach; the 
above-mentioned Kahlbaum's fluoro- 
scope is applied to the upper left ab- 
dominal wall and observed in an ab- 
solutely dark room. (The latter is 
essential, the eyes must also first ac- 
custom themselves to the darkness, 
which usually takes one to three min- 
utes.) A figure is then observed re- 
sembling the stomach and of the color 
of the moon. Around this figure a 
faint halo may be seen to the left 
above the stomach up to the ensiform 
process, to the left axillary line and 
even to the left side of the back (where, 
however, it is much fainter), i.e., the 
lungs above the stomach and the 
diaphragm are transilluminated. To 
the right the liver does not transmit 
the rays and the screen remains dark. 
If the screen s moved further down 
over the abdomen the illumination 
usually ceases below the larger curva- 
ture. Besides we observe a very in- 

spot of illumination (about the size of a big walnut) which 




Fig. 20. — Einhorn's 
Radiodiaphane. 



50 DISEASES OF THE STOMACH. 

corresponds to the position of the radium capsule. If air is 
insufflated into the stomach the illumination is more marked. 
On deep inspiration the illumination becomes weaker (probably 
on account of the greater distance of the abdominal wall from 
the radium capsule) ; on deep expiration, however, the illumi- 
nation becomes much brighter. 

When the radiodiaphane is withdrawn, one observes how 
the intensely illuminated area (of the size of a walnut) travels 
upward, to disappear in the region of the ensiform process. 
When the instrument again descends into the stomach, the 
light at once reappears. 

Radium Photographs of the Stomach. 1 

In a very similar way a radium photograph of the stomach 
can be obtained. The method is as follows: 

The patient should be in fasting condition (empty stomach). 
The radiodiaphane containing 0.05 gm. (or more) of pure 
radium bromide is introduced into the stomach. Patient 
occupies a recumbent position and a photographic plate 
(Cramer's x-ray plate) enclosed in a dark envelope is put 
directly over the gastric area and left there for one or two 
hours according to the requirement of the case. The plate is 
then removed and the radiodiaphane withdrawn. The plate 
is then developed. 

I have used this method of taking photographs through 
the stomach on a considerable number of patients. Contrary 
to my expectations, radium enclosed in a quartz flask failed 
utterly to transmit the photographic rays, while thin ordinary 
glass answered the purpose very well. 

The shortest time for obtaining a photograph outline of the 

1 Max Einhorn : On Radium Photographs of the Stomach." The Archives 
of Physiological Therapy, September, 1905. 



RADIUM PHOTOGRAPHS. 



51 



stomach is one hour: in less than an horn* hardly anything is 
visible; one and a half to two horns bring out the outlines more 
distinctly. Insufflation of air into the stomach occasionally 
aids in obtaining a good picture. 

A few of the better radium photographs in my possession 




Fig. 21. — ^Patient A.) Is the same case as shown in Fig. 19 with a moderate amount of 
bismuth in the stomach. The tumor which is anterior to the stomach divides the organ 
into two segments. F. Indicates fundus. P. P. indicates pyloric portion. G. C, indi- 
cates greater curvature. U. indicates umbilicus. P. M. indicates pyloric muscle. D. 
indicates duodenum. T. indicates tumor. Some of the ruga; are distinctly visible. 



are reproduced herewith, and show that transillumination of 
the -tomach by means of radium is feasible. 1 It is even 
possible to recognize an area of light which had to pass through 

1 Max Einhorn: The Archives of Physiological Therapy, 1905. 



DISEASES OF THE STOMACH. 

the posterior wall of the stomach and the back of the thorax. 
One of my negatives shows a key which was hanging below 
the left scapula and was thus photographed by the trans- 
mitted light from the stomach. 




Fig. 22. — (Patient R.) Shows a case in which the stomach and a considerable portion 
of the intestines have been inflated with air. G. C. indicates the greater curvature. U. 
indicates umbilicus. L. indicates liver which is considerably prolapsed, and the border of 
which is very distinctly shown. P. indicates pylorus. The elongated and prolapsed 
liver is the most important feature in this case. 



Considerable tumors of the stomach or liver (left lobe) can, 
sometimes, be recognized on the picture by the diminished 
translucency. Thus far, however, I have not succeeded in 
obtaining definite outlines of the growth. 



EXAMINATION OF THE FUNCTIONS. 



53 



Examination of the Functions of the Stomach. 
Secretory Function. 

Ewald and Boas 1 have studied the normal condition of 




Fig. 23. — Cow horn Stomach (Hubst). The outilne of the colon also the lower part 
of the small intestine i3 visible, the bismuth having been taken twenty-four hours 
previously. 

gastric secretion in man. According to their observations, as 

1 Ewald and Boas: Virchow's Archiv, vol. 101, p. 325. 



54 



DISEASES OF THE STOMACH. 



soon as food enters the stomach, this organ begins to secrete 
its specific juice and continues to do so until the food has 
passed into the intestine. During the last period, however, 




Fig. 24. 



-Normal colon immediately after an enema of the following mixture: 
Subcarbonate 3ii> Mucilage of Acacia 3xii. Aq, ad. gxxx. 



Bismuth 



the secretion is but very slight. This is the reason why exami- 
nations of the gastric contents reveal different results if made 
at various periods after partaking of food. In order to be 



EXAMINATION OF THE FUNCTIONS. 55 

able to judge in an exact manner whether the gastric secretion 
is normal or not, we must always make the examination under 
equal conditions, that is, after a certain meal. Several test 
meals have been proposed for this purpose. 

1. Leube-RiegeVs Test Dinner. 
The oldest form of test meal is the test dinner of Leube and 




Fig. 25. — Mrs. M. 8. Radiumphotograph of Stomach, taken on May 21st, 1905, with 
0.07 gm. radium bromide and one hour exposure. The ring was placed on the navel; the 
upper part of the plate corresponded to the ensiform process. There is an area of light 
marking the gastric cavity, the stomach extending just to about the navel. 

Riegel. This consists of a large plate of soup (pbout 400 c.c), 
a large portion of meat (beefsteak or something of that kind), 
Borne potatoes, and a roll. The time for examination is about 
three to four hours after partaking of this meal. 



50 



DISEASES OF THE STOMACH. 



2. The Test Breakfast of Ewald and Boas. 

This is taken in the morning in a fasting condition and 
consists of one to two rolls (35-70 gm.) and one cup of tea or 
water (300-400 c.c). Time for examination, about one hour 
after the meal. 




Fig. 26.— Racliumphotogram of H. S., Taken May 10th, 1905, with Tumor of the Liver 
Overlapping the Stomach. Radium bromide 0.07 gm., 1 1/2 hours exposure, lying. The 
upper part of the plate corresponded to the ensiform process, a ring was attached to the 
navel. The very bright circle probably corresponds to the radium capsule; part of the ring 
to the left is visible as a shadowy curve, while its right part was too near the radium and thus 
does not show. The stomach outlines appear quite distinctly on left side of the picture, 
while to the right the tumor darkened the field. In the lower portion of the picture 
there is a lengthy, grayish area which may have been caused by an intestinal coil filled 
with gas and partly transilluminated. 

3. Germain See's Test Meal. 

This consists of 60-80 gm. of scraped meat and 100-150 gm. 
of white bread. Examination takes place two hours after the 
ingestion of the food. 



EXAMINATION OF THE FUNCTIONS. 57 

4. Klemperer's Test Meal. 

This consists of one pint of milk and two rolls. Examination 
takes place two hours afterward. 

The two test meals that are mostly hi use are the Leube- 
Riegel's test dinner and Ewald-Boas' test breakfast. In 1888 
I 1 made a comparative study of the results obtained three 
to four hours after the test dinner, and those derived in the 
same cases one hour after Ewald's test breakfast. In some 
persons I was able to find free hydrochloric acid after the test 
breakfast, but not after the test dinner. Besides, the degree 
of acidity was more constant in the same individual after the 
test breakfast than after the dinner. Moreover, we are able 
to recognize some remnants of food from the previous day 
much more easily after the test breakfast than after the test 
dinner. As the test breakfast consists only of water and rolls, 
any other particles of food found in the gastric contents, as for 
instance meat, asparagus, would indicate that these substances 
have been left there from a previous meal. The test dinner 
being quite a complicated meal, does not allow us to recognize 
this so clearly, and it is necessary to examine the patient again 
in a fasting condition in case there is suspicion that the motor 
function of the stomach is impaired. These advantages have 
also been recognized by other authors, and nowadays almost all 
agree in preferring the test breakfast to the other test meals. 

The stomach contents may be obtained for purpose of exami- 
nation by the following methods : 

By means of the soft-rubber tube and either aspiration or 
expression. In using the tube it is best to have one with 
several openings at the lower end and to attach a small glass 
tube about three to five inches in length to the upper end (see 
Fig. 27). The tube is first immersed in a pitcher of warm 

1 Max Einhorn: "Probemittagbrod oder Probefriihstuck." Berl. klin 
Wochenschr., 1888, No. 32. 



58 DISEASES OF THE STOMACH. 

water. The patient is provided with a bib or towel around 
his neck and sits on a chair, holding a wide-mouthed bottle in 
Ins left hand, near his chest; the physician takes the tube 
from the pitcher, places the glass end piece into the bottle, 
tells the patient to open his mouth, and inserts the tube, push- 
ing it forward into the pharynx. (The physician need not insert 
his ringer into the mouth of the patient.) The patient is now 
told to swallow once or twice, and the tube is rapidly pushed 
with the right hand into the stomach (about 44-45 cm.). 

In using aspiration, one can either attach a Politzer bulb 
over the glass piece (Ewald) or Boas' aspirator, which con- 
sists of a rubber bulb having two soft-rubber ends provided 
with a clamp (see Fig. 28). The bulb is first compressed and 
then released, and in this way aspiration is secured and the 
bulb fills itself with the gastric contents. 



Fig. 27. — Ewald's Stomach Tube. 

Ewald-Boas' Expression Method. — The expression method 
consists in having the patient exert pressure upon his stomach 
by means of his abdominal muscles. This is best done by telling 
the patient first to inspire deeply and then to compress his 
abdominal walls in the same manner as during defecation. 
The pressure exerted in this way upon the gastric contents 
expels them through the tube into the bottle. This expression 
method is now almost exclusively practised everywhere. It 
is the easiest and best way of obtaining the gastric contents. 
If the expression does not bring forward any contents, it is 
well to blow in air (from the mouth) into the tube, to let the 
air escape, and then withdraw the tube. There is usually 
enough chyme in the tube for examinations. 

Before removing the tube, it is necessary to occlude the glass 
opening with a finger of the right hand and to withdraw the 



EXAMINATION OF THE IXGESTA. 59 

instrument quickly from the stomach. (By closing the open- 
ing we avoid the return of some of the food particles contained 
within the tube into the oesophagus or pharynx; the tube is 
then emptied into the bottle containing the stomach contents). 
The ingesta obtained in the above-described way one to one 




\spiratur. 



and a half hours after the test breakfast are then filtered, and 
the nitrate is subjected to the following tests: 1. Reaction. 
2. Hydrochloric acid. 3. Lactic acid. 4. Acidity. 5. Pro- 
peptone. 6. Peptone. 7. Pepsin. 8. Rennet ferment. 9. 
Dextrin. 10. Erythrodextrin. 11. Achroodextrin. 12. 
Maltose. 

Examination of the Ingesta. 

1. The Reaction 

Is determined by means of litmus paper (blue and red). If the 
filtrate is acid it turns blue litmus paper red. 

2. Hydrochloric Acid. 

Many coloring matters undergo some change when brought 
together with even weak solutions of free hydrochloric acid. 
Methyl violet (weak one-per-cent. solution) turns blue; fuchsin 
is .-lightly discolored; tropaeolin (saturated solution) turns 
from yellow to dark red-brown; benzo-purpurin turns from 
intense red to light red; Congo red (one-per-cent. solution) or 
Congo paper turns from dark red to dark blue. Of all these 



60 DISEASES OF THE STOMACH. 

colors. I think Congo red is the most reliable one. As organic 
acids when present in considerable quantity may also give 
these color changes, it is of great importance to have another 
reaction for hydrochloric acid winch the organic acids do not 
si 10W. 

Giinzburg 1 s Phloroglucin- Vanillin Test.- — Giinzburg 1 first 
taught us such a test with his phloroglucin- vanillin solution. 
This solution contains two parts phloroglucin, one part vanillin, 
and thirty parts alcohol. The test is made in the following 
manner: One drop of the filtrate is put on a porcelain dish. 
A drop of the phloroglucin- vanillin solution is added and well 
mixed with a glass rod. The porcelain dish is now heated 
over a spirit lamp and the fluid allowed to evaporate slowly. 
The presence of even small quantities of hydrochloric acid 
gives rise to a beautiful cherry-red color. If there be only 
traces of free hydrochloric acid, the margin of the examined 
spot turns cherry red. 

Boas' 2 Resor tin Sugar Test. — The solution consists of resorcin 
5.0, sacch. albi 3.0, alcohol ad 100. The test is made exactly 
in the same way as with the phloroglucin- vanillin solution. 
The hydrochloric acid is recognized by giving a cherry-red 
color with the Boas reagent. This test is also very reliable, 
but, as I 3 have shown, less sensitive than the Giinzburg re- 
action. 

3. Lactic Acid. 

Uffelmanri's Test. — The best test for lactic acid is made with 
the UfTelmann 4 solution, which has always to be freshly pre- 

1 Giinzburg: "Neue Methode zum Nachweis freier Salzsaure im Magen- 
inhalt." Centralblatt f. klin. Medicin, 1887, No. 40. 

2 J. Boas: "Ein neues Reagens fur den Nachweis freier Salzsaure im 
Mageninhalt." Centralbl. f. klin. Medicin, 1888, Xo. 45. 

3 Max Einhorn: " Die neueren Methoden der Magenuntersuchung." New 
Yorker medicinische Monatschrift, Marz, 1889. 

4 Uffelmann: Deutsches Archiv f. klin. Med., vol. 26, p. 431. 



EXAMINATION OF THE IXGESTA. 61 

pared before use. It consists of a two-per-cent. carbolic-acid 

solution in water, to which is added a drop of sesquichloride of 
iron. Tins test solution has an amethyst-blue color. Place 
about 2 c.c. of tins Uffelmann solution in a test tube, and add 
a few drops of the filtrate. The presence of lactic acid brings 
on a canary-yellow color; the presence of fatty acids produces 
an ashy-gray color, whereas inorganic acids decolorize the blue 
color of the Uffelmann solution. 

As some phosphates are liable to give the same reaction 
with the Uffelmann solution as lactic acid, and as these salts 
are very often present in the gastric contents, the surest way 
to discover the presence of lactic acid in the filtrate is the 
following: o or 10 c.c. of the filtrate are well shaken for quite 
a while in a test tube with a double quantity of ether. Then 
the tube is allowed to stand a few minutes until the ether has 
separated from the watery solution. Pour the ethereal portion 
into another test tube, which is placed in a glass of hot water, 
so as to allow its contents to evaporate. After evaporation 
has taken place, only a few drops remain in the test tube. 
Add 1 to 2 c.c. of distilled water and test for lactic acid with 
the Uffelmann solution. If a canary-yellow color now arises, 
the presence of lactic acid is positively shown. 

Instead of evaporating the ether Fleischer 1 recommends 
testing the poured off ethereal extract directly with the Uffel- 
mann solution; the presence of lactic acid gives the canary- 
yellow color above described. 

A new test for lactic acid has been suggested by Arnold. 2 

The test solution consists of two reagents: (1) A solution of 

gentian violet (0.2 c.c. saturated alcoholic solution. in 500 c.c. 

distilled water), and (2) 5 c.c. of the tinctura ferri perchloridi, 

S. P., diluted with 20 c.c. distilled water. A drop of the iron 

'Fleischer: " Milchs&urenachweis im directen Aether." Cited from 
Penzoldt: Deutsch. Arch. f. klin. Medicin, Bd. li.. p. ")44. 
-Arnold: Journ. Araer. Mod. Assoc, 1898, vol. viii., p. 21. 



62 DISEASES OF THE STOMACH. 

solution strikes a blue color with 1 c.c. of the gentian violet, 
winch changes to a green or yellow-green when a few drops of 
gastric contents containing lactic acid are added. 

Vonrnasos' Test for Lactic Acid. — Vournasos 1 and Croner and 
Cronheim 2 describe a new test for lactic acid. 

The principle of it is based on the fact that lactic acid, when 
brought into contact with iodine and an alkali, forms iodoform. 
The latter is then converted by the addition of methylamin or 
anilin into isonitril, which is easily recognized by its pungent 
odor. 

Test Solution. — Dissolve 2 gm. of potassium iodide (KI) and 
1 gm. of sublimed powdered iodine (I) in 5 c.c. of water; filter 
over asbestos; add water to the filtrate to make 50 c.c. Then 
add 5 c.c. of anilin and keep the solution in a dark bottle. 
Shake before using. 

Mode of procedure: The filtrate of the gastric contents is 
made strongly alkaline by the addition of a 10-per-cent. solu- 
tion of potassium hydrate, boiled for a few minutes, and then 
mixed with a few c.c. of the above test solution. 

If lactic acid is present, there appears, either immediately 
or after a repeated boiling, the pungent odor of isonitril. 

The chemical formula for the process which takes place is 
the following: 



1. 2CH 3 -CHOH-COOH + 10KOH + 12I = 
4HCOOK + 6HI + 2CHI 3 + 4H 2 0. 

2. CHI 3 + 3KHO + CH 5 NH 2 = 3KI + C H 5 N 2 + 3H 2 O. 



Boas' Procedure for the Qualitative Determination of Lactic 
Acid. — The principle of this method consists in the fact that 
when solutions of lactic acid are treated and heated with 



1 Vournasos: Deutsche med. Wochenschrift, 1893, No. 34. 

2 W. Croner and W. Cronheim: "Ueber eine neue Milchsaureprobe ." 
Bed. klin. Woch., 1905, No. 34, p. 1080. 



EXAMINATION OF THE IXGESTA. 63 

oxidizable substances, a splitting of these occurs into acetalde- 
hyde and formic acid, according to the following formula: 

CH 3 -CH (OH)-COOH = CH 3 -CHO + CHOOH. 
Lactic acid Acetaldehyde Formic acid. 

The method of procedure is as follows: Take 10-20 c.c. of 
the filtrate and evaporate in a porcelain dish over the water- 
bath to a syrupy consistence. (If hydrochloric acid was 
present, then the addition of barium carbonate during the 
evaporation is necessary.) Add a few drops of phosphoric 
acid, expel the carbonic acid by boiling, and after cooling, 
extract with small portions of ether (two or three times, 50 
c.c. each). After stirring for half an hour pour off the clear 
layer of ether. The ether is now evaporated; the residue, 
taken up with 45 c.c. of water, is well shaken and filtered. 
To the filtrate add 5 c.c. of concentrated sulphuric acid (sp. 
gr. 1.89) and a knife-pointful of manganese. The mixture is 
now distilled and the vapors conducted into a cylinder which 
contains either 5-10 c.c. of an alkaline solution of iodine (i.e., 
equal parts of decinormal iodine solution and standard potas- 
sium-hydrate solution), or the same quantity of Nessler's 
reagent. If the lactic acid is present, the aldehyde escapes 
with the vapors and gives rise to the formation of iodoform 
(turbidity and iodoform smell, Lieben's reaction), or (with 
Nessler's reagent) of the yellowish-red aldehyde of mercury 
as shown by the yellow color. 

On the same principle, Boas also devised a quantitative 
method for determining the amount of lactic acid. This new 
test has certainly a scientific value, but thus far it has remained 
without practical importance. The procedure is quite com- 
plicated and hardly gives more accurate results than the usual 
test of UrTelmann described above. 

4. Acidity. 

The degree of acidity is examined by adding a drop of a 



G4 DISEASES OF THE STOMACH. 

one-per-cent. alcoholic solution of phenolphthalein to 10 c.c. 
of the filtrate and adding again as many cubic centimetres of 
a one-tenth normal sodium-hydrate solution 1 until a slightly 
red color arises. The amount of cubic centimetres of the one- 
tenth sodium-hydrate solution required for that purpose is 
multiplied by ten and expressed with this figure — i.e., the 
degree of acidity is expressed by the number of cubic centi- 
metres of a one-tenth normal sodium-hydrate solution required 
to saturate or make slightly alkaline 100 c.c. of the filtrate. 
Thus if we find that 10 c.c. of the filtrate require 6 c.c. of the 
one-tenth normal sodium-hydrate solution in order to bring 
on the red color after the addition of phenolphthalein, we say 
the acidity is 60. The figure of acidity multiplied by 0.00365 
gives the percentage amount of hydrochloric acid. If, for 
instance, the acidity is 60, then the percentage of hydrochloric 
acid will be 60X0.00365 = 0.219 per cent. 

Benedict's Effervescence Test for Gastric Acidity. — Benedict 2 
has devised the following method of testing gastric acidity. 
Patient takes 100-250 c.c. of a saturated solution of bicarbonate 
of soda, in gulps of 50 c.c. at a time, one hour after Ewald's 
test breakfast, or two to three hours after Leube's test dinner. 
Auscultation of the gastric area is performed immediately. 
If acid is present in the stomach it enters a combination with 
Na of the bicarbonate and C0 2 is liberated. This gas rises to 
the surface of the fluid in the form of bubbles which burst, 
producing a crepitant sound. When no acid is present there 
is nothing audible on auscultation. 

Practically the same test has been also described recently 
by Fuld. 3 

1 The normal or standard solution of sodium hydrate contains 40 parts of 
sodium hydrate (chemically pure) to 1,000 parts of distilled water. 

2 A. L. Benedict: "The effervescence Test for Gastric Acidity." N. Y. 
Medical Journal, March 11th, 1911; and Philad. Med. and Surg. Reporter, 
March 6th, 1897. 

3 E. Fuld: Berliner klin. Wochenschr., Oct. 31, 1910. 



EXAMINATION OF THE IXGESTA. 65 

The different elements comprising the acidity, and their 
quantitative determination, we shall describe later on. 

5. Pro peptone. 

The digestive action of the stomach results in the formation 
of propeptones and peptones from the albuminates. The best 
test for the presence of propeptone is the addition of an equal 
part of a saturated solution of sodium chloride to a small 
quantity of the filtrate. Propeptone then, if present, is pre- 
cipitated, and the solution becomes the more turbid the greater 
the quantity of propeptone. In case no precipitate is formed, 
add a drop or two of acetic acid, then the solution will turn 
turbid in case propeptone is present. If heated the solution 
clears up again, and when allowed to cool the propeptone 
precipitates anew, and the solution again turns turbid. 

6. Peptone. 

A few cubic centimetres of the filtrate (best after having 
precipitated the propeptone and filtered) are made strongly 
alkaline by the addition of some sodium-hydrate solution and 
a few drops of a weak (one-per-cent.) sulphate-of-copper 
solution added. The presence of peptone gives rise to a 
purplish or violet-red color (biuret reaction). 

7. Pepsin. 

A thin disc (1 cm. in diameter and about 1 mm. thick) of 
the white of a hard-boiled egg is put into a test tube containing 
. of the filtrate and kept at blood temperature. If hydro- 
chloric acid is not present in the filtrate, it is necessary to add 
two drops of the dilute muriatic acid. The presence of pepsin 
effects a disintegration or a disappearance of the egg disc in 
two to six hours. 

An improvement of this method is Mett's procedure. This 
ists in placing small, calibrated glass tubes filled with 



66 DISEASES OF THE STOMACH. 

coagulated albumen into the gastric juice and estimating the 
amount of pepsin from the quantity of albumen digested in the 
glass tube. 

Bettman and Schroeder 1 have devised a novel method of 
estimating the pepsin. They call it the"foam method;" it 
consists in mixing an albuminous solution with the stomach 
contents and shaking thoroughly until a great deal of foam 
develops. The time it takes for this albumen foam to dis- 
appear indicates the relative amount of pepsin. 

Jakoby and Solms 2 have introduced the ricin test for the 
determination of pepsin. It is made as follows: 1.0 gm. of 
ricin is dissolved in 100 c.c. of a five-per-cent. sodium chloride 
solution, and filtered. Two c.c. of this filtrate is mixed with 
0.5 c.c. decinormal HC1 solution. One c.c. of the diluted 
stomach contents is added and allowed to remain at blood 
temperature for three hours. Ferments clear up the ricin 
deposit. The quantity of pepsin is determined from the 
amount of dilution in which the stomach contents will cause 
a disappearance of the ricin deposit. 

Solms designates that amount of gastric juice which is just 
sufficient to clear up entirely the 2 c.c. of one-per-cent. ricin 
solution in three hours when kept at blood temperature, as 
one pepsin unit. Normally, stomach contents contain about 
100 pepsin units to the cubic centimeter. Witte and others 
made control tests and recommended the method as practical. 

Lately two more pepsin tests have been described. 

Of all methods for the approximate quantitative determina- 
tion of pepsin the ricin test is the most practical. For general 

1 Henry W. Bettmann and J. Henry Schroeder: "Ueber die Bestimmung 
der proteolytischen Kraft des Magensaftes nebst Beschreibung einer Modifi- 
kation der Hammerschlagschen Methode und einer neuen Methode." Arch, 
f. Verdauungskr, 1904, p. 599. 

2 Solms: "Ueber eine neue Methode der quantitativen Pepsinbestimmung 
und ihre klinische Verwendung." Zeitschr. f. klin. Medizin, Bd. 64, Heft 1 
and 2. 



EXAMINATION OF THE IXGESTA. 



07 



use, however 
complicated, 
same. First, 



Jakoby and Solms' method is still a little too 
I 1 have, therefore, attempted to simplify the 
I have had constructed a suitable apparatus 



I • Vpptr Ujsc of Support 

"H l.CK*r Disc 

II • Vulcani tx 5cretu-Cop • 
IT Vacuum Tube 

V: Bax-Gf-Su-pjwTt 

VI 'Wooden-Base 

E-adi Disc of 5apport 
Ma<k Uflold Sir- 
Graduated Tubes- 
Marked atb f and 



feaaa fa 



IP 










on' 








— 








-35 








—3 








CC 








-X, 








/C. 








:-l 








^-J 






1 1 ' 


7 




HP .. 


-3,5 -^ 


P -V 






-3 - 


i -3 






cc ex 


' CC 






-2 -I 


2 -2 






A E 


C 




r l^| 


-1 r| 


Id 

> 






■AppoTQbus NodeDy nmcr^Ajnfncl Ncw'Ygrfc 
Ti)rDr Mot Onbcrn Afjnl- 1908- 
Fig. 29. — Einhorn's Apparatus for Pepsin Determination, after Jakoby-Solms' Method. 

for the test; secondly, I have reduced the time from three hours 
to one-half hour. 

.Max Einhorn: "A Simplification of the Jakoby-Solms Ricin Method for 
a Determination.' : Medical Kecord, August 29th, 1908. 



68 DISEASES OF THE STOMACH. 

The apparatus (see Fig. 29) consists of a cylindrical glass, 
surrounded by a vacuum. This glass tube contains a frame 
holding twelve graduated pepsin tubes. The whole apparatus 
can be filled with water and corked. Each pepsin tube is 
marked with a different letter and shows a mark at 2 c.c, 
3 c.c, and 3.5 c.c. The lower part is, furthermore, graduated 
into millimetres. Thus we may dispense with pipettes and 
measuring glasses. 

Proceed as follows: Fill each pepsin tube up to 2 c.c. with 
one-per-cent. ricin solution, then add up to the 3 c.c. mark 
filtered and diluted stomach contents, and finally add deci- 
normal HC1 solution up to 3.5 c.c. The tube is well corked, 
shaken up thoroughly, and then placed into the frame. The 
letters on the tubes identify the various dilutions. The vacuum 
tube is filled with fairly hot w T ater (50° to 60° C), the frame 
with the pepsin tubes is placed in it, then the apparatus is 
corked and allowed to stand for half an hour. Observations 
are taken of the time at which the deposits in the various 
tubes disappear and are noted. After thirty minutes the 
amount of precipitate left in any of the tubes is recorded. 

The advantage of the modification lies in the fact that the 
test is simpler, that a thermostat is not needed, and that it 
consumes less time. 

In making the test, the dilutions of 10, 20, 40, and 100 are 
most servicable. Normally, the precipitate disappears in a 
dilution of 10 or 20. If a precipitate is present at 10 the 
pepsin is diminished, if it disappears at 40 the pepsin is in- 
creased. In achylia or marked subacidity the filtrate is used 
undiluted or only slightly diluted (2 to 5 times). 

Dr. Laporte and I 1 have investigated the amount of pepsin 
in various disorders of the stomach. 

We examined in all 110 cases. Among these were 48 cases 

1 Max Einhorn and Geo. L. Laporte: "On the Amount of Pepsin in Various 
Disorders of the Stomach." Medical Record, June 19th, 1909. 



EXAMINATION OF THE IXGESTA. 69 

of hypercMorhydria, 4 cases of subaeidity. 21 eases of absence 
of free HC1, and 37 cases of normal acidity. 

In looking over the results we find that there is no strict 
relation between the amount of pepsin and the acidity in the 
group of hyperchlorhydria and normal acidity. 

In fifteen cases of aehylia the ricin deposit was cleared up 
entirely only once, and in five cases of cancer of the stomach 
without free HC1 it also occurred only once. In one case of 
aehylia the amount of pepsin was fairly considerable, as the 
precipitate disappeared in seven minutes. 

Among the cases of hyperacidity we find among forty-eight 
only seven that show a correspondingly increased amount of 
pepsin. In all other cases of hyperacidity the amount of pepsin 
did not exceed the normal limits. 

8. Rennet Ferment. 

Take about 5 c.c. of milk in a test tube and add three to four 
drops of the filtrate. Mix thoroughly and keep the tube in a 
glass of warm water. In about ten to fifteen minutes the milk 
becomes curdled. In case coagulation does not occur in an 
hour or two. then no rennet ferment is present, although rennet 
zymogen may exist. To test for the latter, it is necessary to 
add to the same specimen of milk a few drops of a one-per-cent. 
chloride-of-calcium solution, and again allow it to stand a few 
minutes. If the milk remains uncurdled even then, there was 
no rennet zymogen present, otherwise the coagulation would 
have taken place. 

9-12. The Products of Starch Digestion. 

The starchy derivatives resulting from the action of the 
ptyalin-digestion begun in the mouth and continued in the 
stomach, consist of erythrodextrin, achroodextrin, and maltose. 
A few drops of Lugol's solution (iod. 0.1, potass, iod. 0.2, aq. 
dest. 200.0) are added to a small quantity of the filtrate. The 



70 DISEASES OF THE STOMACH. 

presence of (9) dextrin turns the fluid blue; (10) erythrodextrin 
gives rise to a red color. The (11) achroodextrin discolors the 
yellowish tint of the Lugol solution, while (12) maltose does not 
change the color of the solution. For maltose or sugar, we can 
besides make use of Trommer's test. 

In the healthy condition, the results of the analysis of the stom- 
ach contents one to one and a half hours after the test break- 
fast are as follows: acid reaction; free hydrochloric acid present; 
lactic acid not present; total acidity varying from 40-60 
( = 0.015 — 0.21 per cent, hydrochloric acid); propeptone 
present in small amount; peptone in larger proportions; pepsin 
and rennet present; sugar present; achroodextrin present; 
erythrodextrin present in small amounts or absent; dextrin 
absent. From these normal standards we find many deviations 
in the sick, and we shall have to investigate later on the chemical 
processes in the stomach in all disturbances of this organ. 

Although the above tests will suffice for the great majority 
of cases, we find it necessary to give a few additional methods 
which are not complicated and which will serve to determine 
several factors in the gastric analysis more minutely. The 
acidity of the gastric contents is as a rule due to acid salts, acid 
compounds of albumin, and free acids (hydrochloric and lactic, 
and sometimes various organic acids). It is sometimes of 
importance to ascertain the presence, respectively the quantity, 
of each of these factors separately. 

Volatile Acids. 

The presence of fatty or volatile acids is recognized by boiling 
a few cubic centimetres of the filtrate in a test tube. A strip 
of wet, blue litmus paper is held over the vapors escaping at 
the top of the test tube. Their presence will turn blue litmus 
paper red. The quantity of these fatty acids can be ascertained 
by boiling 10 c.c. of the filtrate for about half an hour, adding 
to the residue sufficient distilled water until the quantity 



EXAMINATION OF THE INGESTA. 71 

amounts again to 10 c.c., and now determining the degree of 
acidity in this liquid by phenolphthalein and sodium hydrate. 
This figure subtracted from the figure of the total acidity of 
the filtrate will give the quantity of the fatty acids. 

Acetic Acid. 

Acetic acid if present in larger quantities can easily be 
detected by its characteristic smell; if present in smaller quanti- 
ties it may be detected by neutralizing the watery residue of 
the ethereal extract with carbonate of soda, and then adding 
neutral chloride-of-iron solution, when a beautiful red color is 
developed. 

Estimation of Lactic Acid. 

The quantitative determination of lactic acid may be made 
in the following way: 10 c.c. of the filtrate are well shaken with 
a larger quantity of ether. The ether is then separated from 
the watery solution and the degree of acidity determined in 
this. By subtracting the figure thus obtained from the total 
acidity and multiplying by 0.09, we have the percentage of 
lactic acid. This method presupposes the absence of volatile 
acids; if they are present, they have to be first eliminated by 
boiling. The further steps in the process of determining the 
quantity of lactic acid will then be performed in the way 
described. 

Estimation of Free Hydrochloric Acid. 

This can be done by any one of the following methods: 

1. Mints? 8 1 Method. — To 10 c.c. of the filtrate decinormal 

sodium hydrate is added in such a quantity that a drop of the 

mixture no longer responds to Gunzburg's phloroglucin-vanillin 

The amount of the decinormal soda solution used multi- 

- Mintz: "Eino einfache Methode zur quantitativen Bestimmung dor 
Salzaaure Lm Mageninhalt." Wiener klin. Wochenschr., 1889, No. 20. 



72 DISEASES OF THE STOMACH. 

plied by ten gives the figure of the free hydrochloric acid. The 
percentage of free hydrochloric acid can be obtained from this 
figure in the same manner as above stated for the total acidity, 
by multiplying it by 0.00365. 

2. Method of Moerner 1 and Boas. 2 — The degree of acidity of 
free hydrochloric acid is here determined either by Congo paper 
or by a one-per-cent. solution of Congo red as an indicator which 
turns blue in the presence of the acid. The decinormal soda 
solution is then added until the blue color begins to turn red. 
Boas takes 5 c.c. of the filtrate and 5 c.c. of the watery Congo- 
red solution (one per cent.) . I myself add only one or two drops 
of the same solution to the filtrate. The estimation is done in 
the same way as before. 

3. Toepfer's 3 Method. — Toepfer makes use of dimethylamido- 
azobenzol in a half-per-cent. alcoholic solution for the recogni- 
tion and the estimation of the amount of free hydrochloric acid. 
Hydrochloric acid even in small quantities gives a red color 
with this indicator. The decinormal solution of sodium 
hydrate is added until the red color disappears; a faint yellow 
color arises. 4 This method has been thoroughly studied in 
this country by J. Friedenwald 5 and highly recommended. 

From my own experience I would recommend this method 
for the quantitative determination of free hydrochloric acid, 
when the presence of the latter has been first demonstrated by 
Giinzburg's test; for lactic acid, if present in considerable 
quantity, may also give a positive reaction with Toepfer's 
solution. 

1 Moerner: Maly's Jahresbuch f. Thierchemie, vol. 19, p. 253. 

2 Boas: Centralbl. f. klin. Medicin, 1891, No. 2. 

3 G. Toepfer: Zeitschr. f. physiolog. Chemie, Bd. 19, Heft i., 1894. 

4 If desirable, both indicators (phenolphthaJein and Toepfer's solution) 
can be added at once, and the determination of free hydrochloric acid and 
total acidity computed simultaneously. An alcoholic solution containing 
one per cent, phenolphthalein and one-half per cent, of dimethylamido- 
azobenzol will still better serve this purpose. 

5 J. Friedenwald: Medical Record, April 6th, 1895. 



EXAMINATION OF THE IXGESTA. 73 

In a paper on this subject 1 published some time ago it 
can be easily seen that lactic acid ; if alone present, responds 
to Toepfer's test even if it exists in a percentage above 0.1, and 
in gastric contents if present in a percentage of 0.2. 

Estimation of Combined Hydrochloric Acid. 

The combined hydrochloric acid may be determined according 
to Toepfer by titrating with sodium alizarin sulphonate (1 per 
cent.) until the appearance of a violet color, and deducting the 
found acidity from the total acidity with phenolphthalein as 
an indicator. Toepfer asserts that alizarin is sensitive for all 
the elements comprising the acidity except for the combined 
hydro chloric acid. 

In case free hydrochloric acid is absent, and it should be 
important to ascertain whether combined hydrochloric acid 
is present, the following method suggested by Sjoequist 2 and 
modified by Ewald 3 may be applied: 10 c.c. of the filtrate are 
mixed with about one-half gram barium carbonate in a plati- 
num receptacle. The fluid is then evaporated to dryness and 
reduced to ashes. After cooling, the residue is dissolved in hot 
water and filtered. Several drops of a concentrated soda 
solution are now added to the filtrate. If the fluid remains 
clear, hydrochloric acid is totally absent. If a precipitate forms 
after the addition of the soda solution, then the amount of this 
precipitate will allow us to judge approximately of the quantity 
of combined hydrochloric acid. 

Estimation of Acid Salts. 
Leo's Method. — The presence as well as the quantity of acid 

'Max Einhorn: "The Dimethylamido-azobenzol or Toopfor's Test for 
Free Hydrochloric Acid.'' New York Medical Journal, May 9th, L896. 
'Sjoequist: Zeitschr. f. physiolog. Chemie, 18S7, vol. 13, Heft 1-2, p. 1. 
3 C. A. Ewald: "Diseases of the Stomach," p. 39. 



74 DISEASES OF THE STOMACH. 

salts is best determined by Leo's 1 method. A few drops of the 
filtrate are put in a watch glass and a small amount of powdered, 
chemically pure calcium carbonate is added, stirred with a glass 
rod, and the reaction tested with blue litmus paper. If it turns 
red, then acid salts are present, for the calcium carbonate com- 
bines only with the free acid but not with the acid salts. 

Leo's method for determining the quantity of free and com- 
bined acid is based on the principle that calcium carbonate 
neutralizes free and combined hydrochloric acid, but not the 
acid salts at ordinary temperatures. As the degree of acidity 
of acid phosphates is larger when calcium chloride is present, 
and inasmuch as this salt is always developed in small quantities 
after the addition of calcium carbonate, Leo determines the 
acidity before and after the addition of the latter, having added 
calcium chloride to both. One proceeds as follows: 

After the separation of all organic acids from the filtrate, 
10 c.c. (first portion) are taken, and 5 c.c. of a concentrated 
calcium-chloride solution added and the degree of acidity is 
determined by phenolphthalein and a decinormal sodium- 
hydrate solution. 

Fifteen cubic centimetres of the filtrate of the gastric con- 
tents (second portion) are again taken and mixed with powder- 
ed, chemically pure calcium carbonate and filtered. Of this 
filtrate 10 c.c. are taken and placed in a bottle provided with 
a rubber stopper in which are inserted two glass tubes, one short 
and the other reaching down nearly to the bottom of the bottle. 
To the upper end of this long glass tube is attached a piece of rub- 
ber tubing terminating in a bulb, by means of which air can be 
introduced into the bottle. After the air has been blown in for 
some time, in order to drive out the carbonic acid that has 
formed, the acidity of the solution is determined with phenol- 
phthalein and decinormal sodium-hydrate solution. By sub- 

1 Leo: "Eine neue Methode zur Saurebestimmung im Mageninhalt." 
Centralbl. f. die med. Wissenschaft, 1889, No. 26. 



EXAMINATION OF THE IXGESTA. 75 

tracting the figure of acidity obtained from the second portion 
from that obtained from the first, we have the amount of acidity 
corresponding to the free and combined hydrochloric acid. 

If no organic acids have been present in the filtrate, the last- 
obtained figure, subtracted from the total acidity, will give the 
quantity of acid salts. 

Other More Complicated Methods for the Determination of the 
Quantity oj Hydrochloric Acid. 

Method of Hehner and Seemann. 1 — 10 c.c. of the filtrate are 
neutralized with a decinormal standard solution of sodium 
hydrate, evaporated to dryness over the water bath, and cal- 
cined over the flame. The residue consists of neutral salts + 
carbonate of sodium. The latter is determined in the following 
manner: The residue is washed with hot water and filtered as 
long as the filtrate gives an alkaline reaction. This filtrate is 
then titrated with a decinormal standard solution of sulphuric 
acid, until a slightly acid reaction arises. The amount of the 
decinormal standard sulphuric-acid solution used corresponds 
to the amount of inorganic acid. The difference between this 
figure and the figure of the total acidity expresses the amount 
of free and combined hydrochloric acid. 

Method of Hayem and Winter. 2 — The principle of this method 
consists in the determination, first, of the total amount of 
chlorides; second, of the fixed chlorides (chloride salts); and 
third, of the amount of chlorides combined with acids. Proceed 
as follows: In each of three porcelain dishes (a, b, c) place 5 c.c. 
of the filtrate. To dish a an excess of carbonate of sodium is 
added. All the three dishes are then evaporated to complete 
dryness over a water bath. A solution of carbonate of soda is 
now added in excess to dish b and the contents are again evapo- 
rated to dryness. All the three dishes are then calcined over a 

- ' rnann: Zeitschr. f. klin. Mcdicin, vol. v., p. 272. 
2 Hayem et Winter: "Du Chimi.sme Stomachal. " Pari.-, L891, ]>. 72. 



76 DISEASES OF THE STOMACH. 

Bunsen burner, but the heating should not be carried too far, 
and the calcination should be arrested when there are no more 
points of ignition. To dishes a and b a slight excess of pure 
nitric acid is added and then some distilled water. After 
boiling the contents of these two dishes (a and b), they are 
thrown on a filter. Dish c is treated with boiled water alone and 
then also filtered. The amount of chlorides contained in the 
three different filtrates is then determined by a decinormal 
standard solution of nitrate of silver in the presence of yellow 
chromate of potassium as indicator. Dish a shows the total 
amount of the chlorides (T = chlore total), b = combined + fixed 
chlorine, and c = F = chlore fixe; b — c corresponds to the amount 
of combined hydrochloric acid = C = chlore combine; a — b 
corresponds to the amount of free hydrochloric acid = H = free 
hydrochloric acid. The total acidity is determined by titration 
with a decinormal sodium-hydrate solution and phenolphtha- 
lein as mentioned above. 

Determination of the Hydrochloric Acid Deficit. 

Honigmann and von Noorden 1 advised that the amount of 
combined hydrochloric acid in cases in which free acid is lacking 
be determined by the amount of decinormal standard hydro- 
chloric-acid solution required, in order to give a positive reac- 
tion for free hydrochloric acid, or they really determined the 
deficit of hydrochloric acid which exists in the filtrate, in order 
to combine with all the proteids. The more of the decinormal 
hydrochloric-acid solution it is necessary to add in order to 
give a positive reaction for free acid, the less the amount of 
combined hydrochloric acid in the filtrate. I do not think that 
this procedure is very important, for the degree of acidity alone 
already gives us a sufficient clew as to this condition. More- 
over, the amount of peptone and propeptone qualitatively 

1 Honigmann und von Xoorden: Zeitschrift f. klin. Medicin, Bd. xiii. 



EXAMINATION OF THE INGESTA. 77 

found in the filtrate will also indicate the greater or smaller 
amount of combined hydrochloric acid. If there is no com- 
bined hydrochloric acid whatever, then there will be no biuret 
reaction present. 

During the last two decades a host of methods have been 
described, serving the purpose of determining analytically 
either the free and the combined hydrochloric acids or the 
chlorides. We need only mention the methods of Sjoequist, 1 
Martius and Luettke, 2 and the above-described procedures of 
Hehner-Seeniann 3 and Hayem- Winter. 4 All of these are quite 
complicated and far from being exact. It has been found that 
the gastric contents include considerable quantities of ammonia 
(NH 3 ) in the form of ammonium chloride (NH 4 C1). All the 
methods mentioned are based on results obtained under the 
application of heat, notwithstanding the fact that the latter 
will lead to the evaporation of ammonia and the formation of 
free hydrochloric acid. The error which thus arises merely 
from this circumstance exceeds ten per cent. (Rosenheim, 5 
H. Strauss, and others). 6 But besides the errors of these 
analytical methods, it has been found by the most eminent 
authors that in reference to treatment and diagnosis we do not 
derive from these tests any more data than from the simple 
method of titration and determination of free hydrochloric acid 
(Honigmann, 7 Von Xoorden, H. Strauss, Rosenheim). 8 

For this reason I did not think it necessary to give a detailed 
account of all analytical methods. For practical purposes the 
determination of the total acidity (A = aciditas), of free hydro- 

1 Sjoequist: L. c. 

- .Martius and Luettke: "Die Magensaure des Menschen," Stuttgart, 
1892. 

3 Seemann: Zeitschr. f. klin. Medicin, vol. 5, p. 272. 

* Hayem et Winter: "Du Chimisme Stomachal," Paris, 1891, p. 72. 

'Th. Rosenheim: Centralis, f. klin. .Medicin, 1892, No. 39. 

•H. Strauss: Berl. klin. Wochenschr., 1893, Xo. 17. 

'Honigmann: Berl. klin. Wochenschr.. 1893, Nbs. loand 16. 

8 C. von Xoorden: Berl. klin. Wochenschr., 1893, No. 18. 



78 DISEASES OF THE STOMACH. 

chloric acid (L = acidum hydrochloricum liberum), and the 
qualitative test for lactic acid as above detailed will suffice. 
In some instances Leo's method may also be applied; in this 
way the quantity of combined hydrochloric acid (C = acidum 
hydrochloricum combinatum) and the quantity of acid salts 
may be ascertained. 

Contra-Indications to the Use of the Stomach Tube. 

The application of the tube is not advisable in cases of recent 
hemorrhages, no matter whether from the stomach or from the 
lungs, in all cases of fresh ulcers of the stomach, aortic aneurism, 
and in markedly cachectic and debilitated persons. In cases in 
which there is a mere suspicion of an ulcer, some authors employ 
the soft-rubber tube, while others are opposed to its application. 

Other Methods of Testing the Acid Secretion. 

Notwithstanding the great importance of the results derived 
from chemical analysis of the stomach contents obtained by 
means of the soft-rubber tube, this comparatively new method 
has not as yet been generally adopted by the medical profession, 
for the reason that the examination by means of the tube is 
often unpleasant and repugnant to the patient. Moreover, 
some patients absolutely refuse to undergo this method of 
examination. To obviate these difficulties several other 
methods have been devised: 

1. Giinzburg's 1 Method. — Patient swallows 0.2 gm. potassium 
iodide enclosed in a small rubber bag fastened with fibrin 
threads. After the disintegration of the fibrin by digestion, 
the rubber bag opens and the potassium iodide is now set free 
and ready for absorption. As soon as iodine is detected in the 
saliva, we are sure that the fibrin has been digested and from 
this Gunzburg concluded the presence of hydrochloric acid. 

1 Giinzburg: Deutsche med. Wochenschr., 1889, No. 41. 



EXAMINATION OF THE IXGESTA. 79 

This method, though ingenious, is not adapted for practical 
purposes, for while, on the one hand, it necessitates examining 
the saliva for quite a period of time (one to two hours), on the 
other hand the appearance of iodine in the saliva does not 
conclusively prove that the fibrin has been digested in the 
stomach. The rubber bag may have escaped into the intestine, 
the fibrin may have been digested there, and the potassium 
iodide absorbed. Thus we cannot reach any decisive conclu- 
sion as to the condition of gastric secretion by this method. 
The same remarks apply to Sahli's method, which corresponds 
in most respects to the one just described, except that instead 
of fibrin, catgut is used. 

2. SpaUanzani and Edinger's Sponge Method. — E dinger 1 
fastened a small sponge to a silk thread which he caused his 
patient to swallow. After several minutes he withdrew the 
sponge from the stomach, and examined the contents squeezed 
out for hydrochloric acid. This method, which had been 
practised before by SpaUanzani, is deficient in the following 
particulars: 1. The sponge is partly squeezed out during its 
withdrawal through the narrow passages (cardia and introitus 
oesophagi), and thus much of the gastric contents obtained is 
lost. 2. It absorbs some of the secretions of the oesophagus and 
pharynx. Thus the few remaining drops of gastric contents 
in the sponge are impure (that is, mixed with other fluids) and 
sometimes are altered in their chemical state. 

3. Stomach Bucket (Einhorn 2 ). — The bucket consists of a 
small capsule-shaped vessel (1 3/4 cm. long, 3/4 cm. wide) 
made of silver; 3 on the top there is a large opening surmounted 
by an arch to which a silk thread is tied, and a knot made at a 

1 Edinger: " Zur Physiologie und Pathologie des Magens," Deutsch. Arch. 
f. klin. Medicin, vol. 28, 1881. 

"Mix Einhorn: "A New Method of Obtaining Small Quantities of 
Gastric Contents for Diagnostic Purposes." Medical Record, July, 1890. 

3 Dr. M. Tanaka of Japan uses the smaller-size bucket. He has filled the 
bottom with heavy metal so that it sinks more easily. 



80 



DISEASES OF THE STOMACH. 



distance of sixteen inches from the attachment. [Similar in 
shape but much smaller is the so-called " Duodenal Bucket " 
(Einhorn 1 ) which can be employed for examinations of the 
pylorus and duodenum.] 

Method : In order to obtain a sample of the stomach contents, 
proceed as follows: The bucket is dipped into lukewarm water, 
filled and emptied. (This serves to make the inside of the 
vessel moist, so that it will more easily take up the contents of 
the stomach.) Then the patient is asked to open his mouth 
widely, and the bucket is placed on the root of the tongue 




Fig. 30.— The Stomach Bucket 
(Einhorn). 1, Small size; 2, large 
size; 3, top view. 




Fig. 31.— The Stomach Bucket Set. 



(almost in the pharynx) ; the patient should now swallow once 
or twice. 

The vessel after a short time (one to two minutes) enters the 
stomach. As soon as the knot of the thread is at the lips the 
bucket is in the stomach, for the distance from the teeth to the 
cardia is usually sixteen inches. The vessel is left there about 
five minutes and then withdrawn. During the withdrawal of 
the apparatus a resistance is usually felt at the introitus cesoph- 



1 Max Einhorn : "A New Method of Testing the Permeability of the Pylorus 
and an Attempt of Testing the Pancreatic Function Directly." N. Y. 
Medical Journal, June 20th, 1908. 



EXAMINATION OF THE IXGESTA. SI 

agi. To overcome this difficulty, when the apparatus is at 
that narrow point the patient should swallow. 

By the act of swallowing the larynx is pushed forward and 
upward, and thus the passage is free and the bucket can be 
withdrawn easily. It the stomach is not empty, the bucket 
returns filled and the amount is sufficient for making various 
important tests. In people suffering from an abundant secre- 
tion of the mucous membranes the bucket might become filled 
with mucus before entering the stomach, and then in emptying 
the vessel one would find clear mucus instead of chyme. In 
such cases it is necessary to make the test again and to cover 
the opening with a thin gelatinous capsule, which keeps away 
the mucus from the vessel on its way to the stomach; there the 
capsule is dissolved and the stomach contents can now enter 
the apparatus. On its return from the stomach, the bucket 
being filled, the mucus cannot to any extent enter it. The 
best time for obtaining a sample of the stomach contents is one 
hour after Ewald's test breakfast. 

This way of obtaining a small quantity of gastric contents 
for examination does not give any trouble, nor does it cause any 
exertion to the patient. Even in ulcer of the stomach there is 
no danger whatever from hemorrhage as a consequence of the 
examination For this reason the method seems to be especi- 
ally adapted to all cases where there is suspicion of an ulcer in 
the stomach, and where we desire to avoid the tube. It is also 
suitable for the general practitioner who does not intend to 
make an exact analysis of the gastric contents, but who desires 
to determine whether there exists free hydrochloric acid or not. 
The gastric contents withdrawn in the bucket are examined 
directly without being filtered, in the following way: 

1. By means of blue litmus paper it can be determined 
whether the contents are acid; if so, the paper turns red. 

2. With Congo paper whether there are free acids or only 



S2 DISEASES OF THE STOMACH. 

acid salts. The presence of free acids turns Congo paper blue, 
otherwise the Congo color is not changed. 

3. If there are free acids it is necessary to find out whether 
there is hydrochloric acid present or not. For this purpose take 
one drop of the contents and one drop of Gunzburg's solution 
and mix them thoroughly in a white porcelain dish. This dish 
is now heated over an alcohol lamp; when the fluid evaporates, 
a cherry-red color appears in the same spot whenever hydro- 
chloric acid is present even in a very small amount. 

4. The amount of hydrochloric acid, or the acidity, can be 
approximately determined by gradually diluting one drop of 
the contents with water until the above-mentioned Gunzburg's 
reaction for hydrochloric acid begins to disappear in the diluted 
fluid. Normally the stomach contents can be diluted from 
eight to ten times and yet will give the Giinzburg reaction. In 
this way cases in which we are able to dilute only five times, or 
even less, must be considered as cases of subacidity (too small 
amount of acidity), and cases in which we are able to dilute 
more than twelve times as cases of hyperacidity or superacidity 
(too large amount of acidity). In cases in which no acidity 
whatever is found, we have to deal with anacidity. 

Recently I 1 gauged the amount of hydrochloric acid and also 
that of the total acidity approximately by means of a strip of 
paper saturated with one-half-per-cent. dimethylamido-azo- 
benzol solution and dilution. The method is as follows: A 
minute quantity of stomach contents is placed by means of a 
glass rod upon a strip of dimethylamido-azo-benzol paper (0.5 
by 8 cm.). If the paper turns red, one drop of the contents 
is diluted with two drops of water in a small porcelain dish. 
A glass rod is dipped into the mixture and the test paper again 
touched. If it still turns red, one or two more drops of water 

1 Max Einhorn : " A New Method of Determining Approximately the 
Amount of Hydrochloric Acid in the Gastric Contents." Medical News, 
July 20th, 1901. 



EXAMINATION OF THE IXGESTA. 83 

are added and the procedure is repeated as before. This is 
done until only a slightly red or almost no red color is produced 
by the mixture upon the test paper. In tins way the amount 
of dilution required for a trace reaction with the test paper is 
determined. It is clear that the more hydrochloric acid there 
is in the stomach contents the more they can be diluted, still 
giving a trace reaction with the dimethylamido-azo-benzol 
paper. A dilution of from 3 to 6 corresponds to a normal, 
under 3 to a subnormal acidity, and over 6 to hyperacidity. 

The numbers given refer to the examination one to one and 
one-half hours after Ewald's test breakfast. If we have to 
test after other more complicated meals (test dinner, etc.) 
hyperacidity would be indicated by somewhat smaller amounts 
of dilution (from about six times on), since we estimate approxi- 
mately only the free hydrochloric acid, and the amount of the 
latter is relatively small after meals containing much albumin. 

5. Pepsin and rennet, the two ferments of the stomach, 
generally accompany each other, and we can deduce the pres- 
ence of one from that of the other. We prove the presence of 
the ferments by making the following test for the rennet fer- 
ment: Two drops of the stomach contents are mixed with about 
2 c.c. of milk and kept either in a warm place or in a glass with 
warm water. The presence of rennet curdles the milk in from 
ten to twenty minutes. 

Dr. Dickinson, 1 of Erie, Pa., has made a comparative study 
of the results obtained after an examination by means of the 
tube and a minute analysis of the filtered gastric contents, and 
the result gained after examination with a stomach bucket and 
the coarse method of analysis just described. He examined 
thirteen persons by means of both methods, and found that the 
results harmonized pretty closely. The degree of acidity 

1 Dickinson: "A Comparative Study between the Results Obtained by 
Examination of the Stomach Contents by Means of :i Stomach Tube, and 
Einhorn's Stomach Bucket." Medical Record, September L5th, L894. 



S4 DISEASES OF THE STOMACH. 

corresponded quite accurately to the figure obtained by 
dilution. 

The examination with the tube is as a rule preferable to that 
with the stomach bucket, as the quantity of gastric contents 
obtained with the former is certainly larger, and permits a more 
detailed examination. Wherever, however, the examination 
with the tube is either contraindicated, or where the patients 
refuse its introduction, the examination with the bucket will 
certainly be able to replace the tube and afford us more thorough 
information as to the secretory functions of the stomach. 

4. Duyiham's Thread Test. — A new method of testing the 
acidity of the stomach contents has been devised by E. K. 
Dunham. 1 It consists in having the patient swallow a thread 
colored with litmus, congo, or dimethyl-amido-azo-benzol. 

Thirty inches of thread, with a small tassel attached to the 
end, can be swallowed with from 10 to 30 c.c. of water; a quan- 
tity too small to greatly dilute the contents of the stomach, and 
probably not sufficient to materially modify qualitative tests. 

The apparatus required is very simple; a thread, preferably 
of silk, a cylindrical reel of wood about half an inch in diam- 
eter, a glass tube of small calibre, and a small tassel of test 
threads colored with the desired indicators. The tassel is tied 
to one end of the thread, which is about thirty inches long. The 
free end of the thread is then passed through the glass tube, 
tied to and then wound upon the reel, the tassel being made 
to just engage in the opening of the tube. This reel is then 
floated upon water in a glass, the tassel end of the tube placed 
well over the arch of the tongue, and the water drunk through 
the tube in small, quick swallows. The end of the tube which 
dips into the water should be kept well below the level of the 
reel, otherwise the thread, in passing into the tube, will draw 

1 E. K. Dunham: "A Thread Test of the Acidity of the Stomach Con- 
tents." The New York University Bulletin of the Medical Sciences, vol. i., 
No. 4, p. 178, October, 1901. 



EXAMINATION OF THE IXGESTA. 85 

the reel against the end of the tube and cause too much 
friction. 




Fig. 32. — The Duodenal Pump. A, Metal capsule, lower half provided with numerous 

holes; the upper half communicating with tube B; I, II, III, marks of I =40, 11 = 56, III =70 

cm. from capsule; C, rubber band with silk attached to end of tubing, which can be placed 

Over the ear of patient; F, aspirating syringe; E, collapsible connecting tube; D, three-way 

ock. 

When the act of swallowing has unwound all the thread on 
the reel, the free end is detached from the reel and the tube 



86 DISEASES OF THE STOMACH. 

removed from the mouth. The thread should not be with- 
drawn from the stomach in less than three minutes, and it is 
better to let it remain there for five minutes. After removal, 
it should not be washed lest the original color return to the 
threads dyed with dimethyl-amido-azo-benzol. 

5. The Digestive Juice Aspirator or Duodenal Pump (Ein- 
horn). — The duodenal pump 1 consists of a small metal capsule 
(14 mm. long and 23 mm. in circumference), which is perforated 
and can be unscrewed. This communicates with a long, thin 
rubber tube (8 mm. circumference and one metre long), and is 
marked at 40 (I. cardia), 56 (II. pylorus), 70 (III.), and 80 
cm. distance from the capsule. At its end is a tip, to which a 
syringe can be attached (Fig. 32). It can be used for aspirating 
stomach or duodenal contents, and might aptly be called a 
"duodenal pump" or " digestive juice aspirator." 

Mode of Procedure. — The capsule of the duodenal pump, as 
well as the lower part of the rubber tube, are moistened with 
warm water and put into the pharynx of the patient. Then the 
latter drinks some water, and the instrument thus soon passes 
into the stomach. To be certain that the capsule did not get 
stuck in the ceophagus, it is well to have the patient shake his 
abdomen to aspirate a syringeful of chyme. This can easily be 
identified as gastric contents. Now we pass a syringeful of 
water and then one of air through the instrument. The rubber 
tube is then clamped off and left alone for about one hour. 
The patient is told not to close his mouth too tightly, so that 
the tube is not retarded in its wanderings. The patient must 
also avoid intentional swallowing of the tube. Through the 
peristalsis of the stomach the capsule is pushed on further, and 
usually passes through the pylorus into the duodenum and 
later into the beginning of the small intestine. It is best to 
have the patient read some light literature, in order to divert 

1 Max Einhorn: "A Practical Method of Obtaining the Duodenal Contents 
in Man." Medical Record, Jan. 15th, 1910. 



EXAMINATION OF THE INGESTA. 87 

his attention. After one hour we examine how far the capsule 
has progressed; if sign III is near the lips (70 cm.) or inside the 
mouth, we try to aspirate. If the capsule is in the duodenum, 
we generally obtain a clear, golden yellow or watery liquid of 
alkaline reaction and somewhat viscid consistency. If, how- 
ever, we are in the stomach, we obtain an acid liquid resembling 
the one first removed. This can, of course, occur if the tube 
lies in the stomach in a coiled manner. Should the latter be 
the case, we must partly withdraw the tube, after putting 
water and ah* through it, up to the mark II (56 cm.). The 
tube is then again clamped off, and after one-half to one hour 
the procedure is repeated. We generally succeed in nearly all 
cases (of course, not in such where there is pyloric stenosis) in 
obtaining duodenal contents. After having obtained the desired 
contents the tube is clamped and slowly withdrawn. When 
the beginning of the oesophagus is reached the patient is 
told to swallow, and during this act the capsule is with- 
drawn. 

The same instrument can, of course, also be used to study 
the act of gastric secretion during the entire period of stomach 
digestion from beginning to end. In this case the tube is 
fastened so that it cannot go beyond mark II; the capsule thus 
remains all the time in the stomach. Every half hour or so the 
contents may be aspirated and comparisons of the acidity, etc., 
made, and thus the secretion of the stomach may be studied. 

In examining the contents of the duodenum it is of import- 
ance to have evidence when we are in the stomach and when 
we are in the duodenum. I therefore wish to call attention to 
the following points: 

1. If the capsule is in the stomach and we aspirate, the 
syringe quickly fills with fluid or air, provided that the holes 
an- not clogged by thick food. The heavier rubber tube 
attached to the syringe does not collapse, as this organ is always 
filled with either air or liquid. If, however, the capsule is in 



88 DISEASES OF THE STOMACH. 

the duodenum, one finds that the connecting rubber tube will 
collapse on rapid aspiration. This is caused by a vacuum 
forming, owing to the fact that there is not much air or liquid 
in the duodenum and because the walls of the latter are in close 
apposition to the capsule. (We find the same condition if the 
capsule is in the oesophagus.) After waiting a short while and 
after slowly trying aspiration, fluid enters the syringe. If we 
find a larger supply of bile and pancreatic juice, it appears a 
little quicker, but always slower than from the stomach. 

2. If the capsule is in the stomach and air is forced through, 
the patient feels the entrance of the air very plainly and can 
localize where it occurred. If the capsule is in the duodenum 
or jejunum, the patient does not usually feel the entrance of 
air. 

3. The Milk Test. If we give the patient two or three swallows 
of milk (provided, of course, that no milk has been previously 
taken), and then aspirate with the capsule in the duodenum, 
we obtain pure duodenal contents (golden yellow or clear as 
water) without any admixture of milk. If, however, the 
capsule is in the stomach, the milk appears at once. This milk 
test can be made still more reliable if, after aspiration of clear 
duodenal contents free from milk, we withdraw the tube 
up to mark II and a little further, and on renewed aspiration 
obtain the fluid from the stomach, containing unchanged or 
curdled milk. 

4. The :c-rays show the position of the capsule in the stomach 
or duodenum very plainly. A good apparatus shows not only 
the capsule, but also the course of the tube. 

Preparation of the patient for the purpose of duodenal exam- 
ination. It is best that the patient should take only fluid 
food on the day of examination. In most cases I have had 
him take a cup of tea and sugar without milk half an hour be- 
fore the examination. 



EXAMINATION OF THE INGESTA. 89 

Exact Determination of the Quantity of Chyme within 
the Stomach. 

The quantity of chyme can, as a rule, be determined by hav- 
ing the patient empty the contents of his stomach through the 
tube by means of the expression method. The quantity can 
then be directly measured, and will give the exact figure of the 
gastric contents, provided we are positive that the stomach is 
now empty. This may be determined by blowing air through 
the same tube into the stomach; if no bubbling sound is heard, 
but merely the sound produced by the air on striking the gastric 
walls, the organ may be regarded as empty. Occasionally, 
however, it is quite difficult to withdraw the entire quantity of 
gastric contents (especially in cases of dilatation of the stomach 
with stenosis of the pylorus). In the latter instance, the 
quantity of the gastric contents can be ascertained by the pro- 
cedure described by Mathieu and Remond. 1 This is done in the 
following maimer: Some time after a meal a small portion of the 
contents is obtained by the ordinary expression method. Then 
the tube, while still within the stomach, is attached to the 
funnel arrangement (ordinarily used for lavage) and a certain 
quantity of water (usually 200 c.c.) poured into the stomach. 
By moving the funnel up and down several times and by having 
the patient >hake his abdomen thoroughly, a complete mixture 
of the ingested water with the contents is soon accomplished. 
Another portion of the mixed gastric contents is now obtained. 
By determining the degree of acidity in the first and second 
portions separately, the amount of the original quantity within 
the -tomach can be easily found, according to the following 
calculation : If b represents the undiluted portion withdrawn, 
a the acidity of this liquid, a the acidity of the diluted portion, 
q the quantity of water introduced into the stomach — the 
amount of arid being the same in the diluted liquid as in the 

1 Mathieu et Remond: Soc. de biolog., 8 Nov., 1890. 



90 DISEASES OF THE STOMACH. 

original undiluted gastric contents — the following equation is 
obtained: 

a x = a q + a x 

which is equivalent to 

a q 

x = 

a — a 

The quantity of liquid originally contained in the stomach is 
then represented by the formula : 

a q 



or the quantity of contents originally in the stomach is equal to 
the number of cubic centimetres of water poured in within the 
stomach, multiplied by the degree of acidity of the second 
portion, divided by the figure resulting by deducting the degree 
of acidity of the second portion from the first, plus the portion 
previously withdrawn. 

Abnormal Constituents of the Gastric Contents. 

The gastric contents are sometimes mixed with some abnor- 
mal products, which may be of importance .with regard to 
diagnosis. They may contain mucus, bile and intestinal juice, 
blood, and pus. 

Mucus, if present in considerable quantity, is easily recog- 
nized. It usually occupies the upper part of the fluid, presents 
a more watery color, and can be partly lifted from the surface 
by means of a glass rod on account of its adhesive quality. If 
it is present only in small quantities, its existence in the gastric 
filtrate is best revealed by adding a few drops of dilute acetic 
acid, which then forms a characteristic precipitate, settling 
on the bottom of the vessel. 

Bile and Intestinal Juice. — Small quantities of bile and 
intestinal juice in the stomach are often met with, even normally 
in examination of the patient in the fasting condition. The 



EXAMINATION OF THE IXGESTA. 91 

tube probably produces a slight regurgitation of the duodenal 
contents into the stomach. The frequent occurrence of con- 
siderable quantities of bile and intestinal juice within the 
stomach is always due to some abnormal condition, either to a 
relaxation of the pylorus or to a stenosis of the duodenum, 
situated below the mouth of the bile duct. The presence of 
bile is easily noticed, either by its golden-yellow color or (if 
mixed with gastric juice) by its more greenish aspect. When- 
ever there is doubt as to the presence of bile, the usual test 
which serves for its detection in the urine may be applied. 

The presence of intestinal juice is recognized by the character- 
istic ferments, amylopsin, steapsin, trypsin. 

1. The filtrate is mixed with one-per-cent. solution of carbon- 
ate of sodium until it has a decidedly alkaline reaction. A flake 
of fibrin is then added to the filtrate, which is kept in a warm 
place for quite a while. The fibrin will then dissolve by the 
action of the trypsin. 

2. Starch will be changed into maltose by the action of the 
amylopsin. 

3. To a small portion of milk add a drop of blue litmus tinc- 
ture and a few cubic centimetres of the neutralized filtrate and 
keep at blood temperature. The presence of steapsin very 
soon changes the blue color, and the milk becomes slightly 
reddish (caused by the decomposition of the fat into the fatty 
acids through the steapsin). 

Blood. — Blood, if present in considerable quantities in the 
gastric contents, is very easily recognized. Fresh blood can 
hardly be mistaken for anything else, if present even in small 
quantities. The gastric contents mixed with blood present 
either a reddish or (if the blood is not fresh) a slightly brownish 
or coffee-ground color. Occasionally, if the blood is present in 
large quantities, the contents may appear black. The delect ion 
of blood in gastric contents which do not present the appear- 
ances just mentioned must be made in the following manner: 



92 DISEASES OF THE STOMACH. 

1. A drop of the contents may be examined under the micro- 
scope for the presence of red blood corpuscles. 

2. By the Spectroscope. — If the presence of fresh blood is sus- 
pected the filtrate of the gastric contents may be directly 
examined with the spectroscope. Blood, if present, will show 
the two lines of the oxyhemoglobin. If the blood is not fresh, 
or if the gastric contents include a considerable quantity of free 
hydrochloric acid, then, according to Weber 1 and Boas, 2 the 
ordinary examination with the spectroscope would not show 
the presence of blood, as the hsematin is not soluble in the fil- 
trate. H. Weber therefore suggested the following procedure: 

3. To the gastric filtrate add a few cubic centimetres of 
concentrated acetic acid, and shake thoroughly with sulphuric 
ether. The latter presents a Tokay-wine color if haemoglobin 
or hsematin is present. 

4. Heller's Blood Test. — A small quantity of the gastric 
filtrate in a test tube is mixed with the same quantity of normal 
urine, and sodium-hydrate solution is added until a decided 
alkaline reaction is obtained. The tube is now heated over the 
spirit lamp until it begins to boil. The appearance of a flaky 
dark-red sediment proves blood (the reaction consists in the 
formation of hsematin and its combination with the precipitated 
phosphates). 

5. Schonbdn-Almen's Blood Test. — An. emulsion of equal 
parts of freshly prepared guaiac tincture and ozonized oil of 
turpentine (i.e., old oil of turpentine that has been exposed to 
the air) is poured into a test tube over the gastric filtrate: a 
white ring forms at the point where both mixtures meet, which 
ring assumes a Prussian blue color if haemoglobin is present. 
Instead of ozonized oil of turpentine the following solution, 
which was proposed by Huhnerfeld, may be used: 

1 H. Weber: Berliner klin. Wochenschr., 1893, No. 19. 

2 J. Boas: " Diagnostik und Therapie der Magenkrankheiten," Theil 1, 
3te Auflage, p. 206. 



EXAMINATION OF THE IXGESTA. 93 

R Acid, acetic, glacial.. 2 

Aq. dest.. 1 

Terebiuthin. et spirit vin rectif., aa 100 

6. Teichmann's Hoemin Test. — A small quantity of the gastric 
contents is evaporated in a porcelain dish over a spirit lamp. 
A small part of the residue is placed on a slide and mixed with 
a quantity of pulverized common table salt. A drop of glacial 
acetic acid is poured over it, covered with a cover-glass, and 
slightly heated over a spirit lamp until small bubbles begin to 
rise. Another drop of acetic acid is now again added, and the 
specimen examined under the microscope. The presence of 
ha?min crystals (rhomboid shape and beautiful reddish color) 
proves blood. 

7. Korczynski and Jaworskis 1 Blood Test. — A small quantity 
of the filtered residue is placed in a small porcelain dish, a trace 
of chlorate of potassium and a drop of concentrated muriatic 
acid are added, and the mixture is slowly heated over a spirit 
lamp. After all the chlorine gas has escaped, one or two drops 
of a dilute solution of potassium ferrocyanide are added; a 
distinctly blue color (Berlin blue) arises if blood is present. 

8. In cases in which there is suspicion that small hemorrhages 
take place in the stomach although not visibly changing the 
color of the chyme (" occult blood") Boas 2 often examines the 
faeces for blood. The object of this method is to exclude the 
possibility of having caused a small abrasion and some bleeding 
by the tube. 

It is best for this purpose not to give the patient any meat for 
the previous twenty-four hours. 

Proceed as follows: 5 c.c. of the faeces are treated with about 20 
c.c. of ether: the latter is then poured off; 2 c.c. of glacial acetic 
acid are now added to the faeces and thoroughly stirred. This 

1 Korczynski and Jaworski: Deutsche med. Wochenschr., 1887, Xos. 47- 
40. p. 35. 

2 Boa-: Arch, fur Yordauungskr., 1902. 



94 DISEASES OF THE STOMACH. 

mixture is again treated with about 10 c.c. of ether and then 
allowed to separate. This ethereal extract is now used for the 
test. To 2 c.c. of the extract add 2-3 drops of a freshly pre- 
pared tincture of guaiac. Then add 20-30 drops of either 
ozonized oil of turpentine or of pure hydrogen peroxide, and 
shake well. At the presence of blood there appears a clear blue 
or brownish-blue color. 

Instead of the guaiac tincture Klunge uses aloin, which is 
freshly prepared. Take as much aloin as can be placed on the 
tip of a spatulum and dissolve in 10 c.c. of 70-per-cent. alcohol; 
2 c.c. of the aloin solution are added to 2 c.c. of the ethereal 
extract of the faeces as above described, and then either oil of 
turpentine or peroxide of hydrogen as in the previous test. If 
blood is present the lower half of the fluid will turn cherry-red 
after standing a short time. 

Both the guaiac and aloin tests are very sensitive. 

9. Recently a new test with benzidin has been described by 
0. and R. Adler. 1 According to Schlesinger and Hoist 2 it is 
made as follows: (1) A knife point full of benzidin (Merck's) is 
added to 2 c.c. of glacial acetic acid and allowed to stand. 
(2) A small piece of faeces (about the size of a pea) is mixed 
with 2 c.c. of water and boiled in a test tube closed with cot- 
ton. (3) Ten to twelve drops of benzidin solution are added to 
2 1/2 to 3 c.c. of a three-per-cent. peroxide of hydrogen solu- 
tion. (4) Three to four drops of the boiled faecal solution are 
added to reagent three. In the presence of blood a green or 
blue color results. 

For the testing of stomach contents Schlesinger and Hoist 
advise boiling the filtrate and proceeding in a similar manner 
as in testing the faeces. 

The guaiacum-aloin, or benzidin test, require the preparation 

1 O. and R. Adler: Zeitschr. f. phys. Chemie., vol. 41, Heft 1 u. 2, p. 59. 
• Schlesinger and Hoist: Deutsche med. Wochenschr., 1906, No. 36, p. 
1444. 



EXAMINATION OF THE IXGESTA. 95 

of fresh solutions, which makes the test more difficult. I 1 
therefore have tried to simplify the test by making a reagent 
paper. I prepared an aloin paper and a benzidin paper. 
Aloin paper was made by saturating ordinary filter paper with 
a solution of aloin in seventy-per-cent. alcohol; the benzidin 
paper by moistening filter paper with a saturated solution of 
benzidin and glacial acetic acid, and drying it. In preparing 
the paper, as v\ell as in making the test, it is of importance to 
avoid contact with the fingers, as a drop of perspiration causes 
a similar reaction. In handling the paper it is best to use an 
ivory tipped forceps, or protect the hand by means of a towel. 
Aloin paper is much inferior in sensitiveness to benzidin paper; 
I would, therefore, recommend the latter. 

Mode of Procedure. — A piece of benzidin paper is immersed 
in the solution to be examined and a few drops of hydrogen 
peroxide are added. The piece of paper is placed on a piece of 
white porcelain and is examined for the development of a blue 
color. In the presence of blood a green or blue color arises in 
a few seconds to a minute. 

Regarding the sensitiveness of the reaction it is greater, if 
we allow more time for its occurrence. In dilutions of 1 part 
blood to 500 parts of water a distinct reaction occurs in between 
thirty to sixty seconds. In dilutions of 1 to 2,000 a trace of 
blue occurs one to two minutes later. To wait longer for the 
reaction does not seem advisable, as after thirteen minutes the 
benzidin paper with hydrogen peroxide alone without blood 
will yield a blue color. For practical purposes it will be best 
to wait but one minute for the occurrence of the reaction. If 
after one minute there is no trace of blue, then the test must be 
considered negative. 

In examining for blood in stomach contents too great a 
sensitiveness is not important, but rather a certainty that the 
(est will indicate only blood. The longer we wait for the re- 

1 Max Einhorn: "A New Blood Test." Medical Record, June 8th, 1907. 



96 DISEASES OF THE STOMACH. 

action the more substances besides blood may cause it. Benzi- 
din paper 1 can be used for testing for blood in stomach contents, 
urine, and faeces. For urine it is not as sensitive as an aloin 
ether extract. Faeces of people living on common foods usually 
gives the reaction. The stool of a patient on a milk-and-egg 
diet does not give the reaction, except blood be really present. 
The stool may be examined in the following manner: 

A small piece of faeces (the size of a pea) is rubbed up with 
about 2 c.c. of water, the benzidin paper is immersed; a drop 
of hydrogen peroxide is added, and it is examined for blue color. 




Fig. 33. — A Specimen of Mucus in the Gastric Juice obtained from a Patient in the 
Fasting Condition, showing mucous corpuscles, amorphous material, and few epithelial 
cells. 

10. Phenolphthalein. — E. Meyer 2 and recently Boas 3 have 
recommended phenolphthalein for the discovery of blood. A 
few drops of a one-per-cent. solution of phenolphthalein are 
added to 1 c.c. of the fluid to be tested and a few drops of 
H 2 2 . A reddish color arises when blood is present. 

Pus. — Pus is very seldom found in the gastric contents and 

1 The Benzidin paper must not be too old; for when the acetic acid 
entirely disappears by evaporation, it becomes inactive. In order to 
reactivate the paper, it should be dipped into acetic acid. 

2 Erich Meyer: Munch, med. Wochenschr., 1903, No. 35. 

3 J. Boas: "Die Phenolphthalin probe als Reagens auf occulte Blutungen 
des Magendarm-kanals." Deutsche med. Wochenschr., 1911, p. 62. 



EXAMINATION OF THE IXGESTA. 97 

is recognized by its characteristic appearance under the 
microscope. 

Microscopical Examination of the Gastric Contents. 

(a) Gastric Juice. — The microscopical examination of the 
gastric secretion found when fasting shows normally some 
epithelial cells, cell nuclei, mucous corpuscles, amorphous 
material, and some micro-organisms (see Fig. 33). The occur- 
rence of snail-like cells in cases of hyperchlorhydria was first 
described by Jaworski, 1 who considered them a great rarity. 




F:g. 34. — A Specimen of Mucus in the Gastric Juice obtained from a Patient in the Fast- 
ing Condition, showing single snail forms and some lying in groups; also amorphous material 
and few epithelial cells. 

Boas. 2 on the other hand, is of the opinion that they are of 
frequent occurrence. The latter writer considered them as 
substances which have developed from the mucus under the 
influence of the gastric juice. I concur with Boas in his 
statement that the snails are frequently found, and would 
like to add that they may also be found in patients not troubled 
with hyperchlorhydria. I found them once in a patient with 

'Jaworski: Munchener med. Wochenschr., 1887, No. 32. 
2 J. Boas: "Diagnostik unci Therap. der Magenkrankheiten," Theil i., 
3te Auflage, p. 212. 

7 



98 DISEASES OF THE STOMACH. 

normal secretion, and once in some fluid which had been 
obtained from the (esophagus of a patient troubled with cancer 
of the cardia. The snails may lie separately or in groups 
(see Fig. 34). 

(b) Gastric Contents. — The microscopical examination of the 
gastric contents at the height of digestion (either one to one 
and a half hours after a test breakfast or three to four hours 
after a test dinner) will allow us to judge to a certain extent 
regarding the way the act of digestion has progressed. Nor- 




Fig. 35. — A Specimen of Gastric Contents in the Fasting Condition from Patient K., 
with Carcinoma Ventriculi. a and b, Partly digested muscle fibres; c, starch granules; d, 
fat globules; e, yeast cells; /, sarcinse. 



mally only a few starchy granules are found, most of which 
have already lost their characteristic spiral configuration. The 
muscular fibres have likewise already undergone deep changes 
and do not show diagonal stripes. Plant cells, fat in fine 
globules, and different kinds of micro-organisms are found in 
small numbers. The presence of a large amount of unchanged 
starchy granules is most frequently found in cases of hyper- 
chlorhydria, while unchanged muscle fibres, showing the diag- 
onal stripes clearly, are found in cases with a diminished gastric 
secretion. The different varieties of micro-organisms found 



EXAMINATION OF THE INGESTA. 



99 



in the stomach have been thoroughly studied by De Bary, 1 
Miller, 2 Macfadyen, 3 Nencki, 4 Abelous, 5 Boas, 6 and others. 
"While a few years ago it was believed that no micro-organisms 
can develop in the stomach containing free hydrochloric acid 
in its juice, of late it has been proven by several authors that 
micro-organisms may thrive in the stomach even if it contains 
too large a quantity of hydrochloric acid — or, in other words, 
the hydrochloric acid (of the gastric juice) does not always 




Fig. 36. — A Specimen of Gastric Contents from Patient with Ischochymia, showing 
sarcinae, yeast cells, fat globules, and fat crystals. 

exclude fermentative processes in the stomach. Thus Kauf- 
mann, 7 of New York, has described a case in which a condition 
of hyperchlorhydria existed and in which the motor function of 
the stomach was not markedly disturbed, but which notwith- 
standing microscopically gave all symptoms of fermentative 
processes. The gastric contents always contained numerous 

1 De Ban-: Arch. f. exper. Path, und Therap., Bd. 20, p. 243. 
'Miller: "Die Mikro-organismen der Mundhohle," Leipzig, 1892. 
3 Macfadyen: Journal of Anat. and Physiol., vol. 21, 1887. 
* Macfadyen, Nencki, und Sieber: Arch. f. exper. Patholog., Bd. 28. 
'Abelous: These de Montpellier, L8$8. 

6 Boas: Deutsche med. Wochenschr., \^'>2. 

7 J. Kaufmann: Berl. klin. Wochenschr., 1895, No. 6. 



100 DISEASES OF THE STOMACH. 

living bacteria of various types. Dr. Kaufmann succeeded in 
separating the eight following micro-organisms from one 
specimen of the gastric contents by means of culture: (1) 
Yellow sarcinse; (2) white yeast; (3) Micrococcus aurantiacus 
(Cohen); (4) Staphylococcus cereus albus (Passet); (5) Bacillus 
subtilis; (6) Bacillus ramosus; (7) a large, thick bacillus; 
(8) a short bacillus, resembling the Bacillus coli communis. 

Boas has observed several cases in which, notwithstanding 
the presence of hyperchlorhydria, there was a decomposition 




Fig. 37. — A Specimen of Gastric Contents One Hour after Test Breakfast (Patient 
with Hyperchlorhydria), showing many unchanged starch granules, yeast cells and a great 
number of micro-organisms. 



of the albuminate of the food, resulting in the development of 
sulphuretted hydrogen. I have lately observed numerous cases 
of this nature myself. In cases with abnormal fermentative 
processes within the stomach, the same kinds of micro-organ- 
isms are usually found as in the normal stomach, only in 
much larger number (Minkowski). 1 Yeast cells and sarcinse 
occur in larger numbers in cases with a distinct motor disturb- 
ance of the stomach (especially ischochymia). The sarcinse 

1 Minkowski: " Mittheilungen aus der med. Klinik zu Konigsberg," 1888. 



EXAMINATION OF THE IXGESTA. 101 

ventriculi. which were first described by Goodsir 1 in 1842, occur 
in cubes or tetrahedrons (see Figs. 35 and 36), but they have 
only a pathognomonic significance if they appear in very large 
numbers. 

(c) Mould Pellicles. — The part which micro-organisms 
(bacteria and mould fungi) play in the occurrence of patholog- 
ical processes in the stomach has been variously interpreted 
by authors. Most clinicians ascribe no special significance to 
them. Others, however, assign them a prominent place; thus, 
for example, Talma 2 maintains that the fermentation of car- 




Fig. 38. — A Specimen of Mucus from the (Esophagus (from a Patient with Carcinoma 
Carl he, J. C. W.), showing mucus, bacteria, fat and epithelial cells, some of the latter 
grouped together. 

bohydrates induced by micro-organisms is the cause of hyper- 
ehlorhydria; others, again, place stress not so much upon the 
variety of these microbes as upon their ultimate number. 
Among these authors Xaunyn 3 may be especially cited. 

The mould fungus, as such, has been but little mentioned in 
the domain of gastric affections. 

'Goodsir, cited from Ewald: "Diseases of the Stomach," New York, 
1892, p. 138. 

-Talma: "Von dor Clahrung der Kohlehydrate im Magen." Zeitschr. 
fQr klin. Medicin, 1808. Bd. 35, p. 542. 

• B. Xaunyn: "Ueberdas Verhaltniss der Magengahrungen." Deutsches 
Arch. f. klin. Med., vol. xxxi. 



102 DISEASES OF THE STOMACH. 

In all literature the scant references to mould fungi in the 
stomach relate to the findings of microscopical examinations. 
Mould itself, recognizable by macroscopic examination, has, 
according to my knowledge, not as yet been observed clinic- 
ally in the stomach. At any rate, no mention of this occurs 
in the literature. I 1 have had occasion to observe several 
cases of mould formation in the stomach. In the cases under 




Fig. 39. — Small Pellicles of Mould found in the Stomach. (Natural size.) 

my observation there were found in the wash water of the 
empty stomach small, sometimes blackish-gray, and some- 
times brownish-green flakes (2 to 5 mm. in diameter; see 
Fig. 39) in varying number (four to fifty and more). The 
microscopical examination showed that these flocculi consisted 
entirely of spores and mycelia and scarcely anything else. 
Similar flocculi were found in the same patients in the gastric 

1 Max Einhorn: "The Occurrence of Mould in the Stomach and its 
Probable Significance." Medical Record, June 16th, 1900. 



EXAMINATION OF THE INGESTA. 



103 



contents after a test meal, and the microscope showed the same 
picture as in the flocculi from the empty stomach. 

Sometimes these blackish-gray masses are embedded in 
mucus. We then note besides these fungus colonies mucous 
corpuscles and numerous epithelial cells. This indicates an 
intimate connection between the fungus colonies and the 
surface of the mucous membrane. The former must adhere 




Fig. 40. — A Greenish Pellicle found in the Wash water of the Stomach (of Wm. R ) 

in the fasting condition. Mycelia, free spores, and a few crystals are visible. X240. 



quite closely to the latter and perhaps even proliferate into 
the epithelial layer. This firm adhesion must be assumed for 
the following reasons: If the fungi were only an accidental 
admixture of the ingesta, that is, introduced with the latter 
and then carried farther onward, without there being any 
fungus proliferation, then they would be encountered only in 
the gastric contents. 

That the grayish-green or grayish-black flakes, which were 



104 



IMSFASHS OF TIIF STOMACH. 



found, represented mould pellicles, was established beyond 
doubt by the microscopical examination. An extremely large 
number of spores and mycelia were always observed. In all 
my cases the microscopical picture was the same, and it can 
therefore be assumed that the mould fungi present belong to 
one and the same species. Dr. E. K. Dunham has identified 
them as penicillium glaucum. 




Fig. 41. — Same as Fig. 40, highly magnified. X420. 

What significance have these mould fungi in gastric pathol- 
ogy? Although isolated fungi may exist in the stomach for 
a short time without any detriment, they do not find in the 
normal organ favorable soil for further development. They 
are intimately mixed with the chyme and are carried onward, 
living or dead, through the pylorus. Entire colonies of fungi 
which are macroscopically perceptible are probably never to 
be found in the normal stomach. Any considerable growth of 
mould would be possible only if a colony of the fungi had 



EXAMINATION OF THE IXGESTA. 



105 



infested a fold of the surface of the gastric mucous membrane 
and had become so firmly adherent that they were not carried 
along with the onward passage of the chyme. Under these 
circumstances a fungus colony may grow undisturbed, and 
considerable areas of the gastric mucosa may become covered 
with mould. In my cases such a condition must have pre- 
vailed. In lavage of the stomach the inflowing current of 
water exerts considerable force and tears many mould islets 




42.— A Blackish Pellicle found in the Gastric Contents (of T. M ) after a 

teakfast. Numerous spores, mycelia, a few crystals, starch granules, and epithelial 
cells are visible. X 140. 

from their bases, so that they then appear in the wash water. 

It is scarcely conceivable that such a mould coaling of 
certain zones of the gastric mucosa can be unattended with 
disturbances of the functions of the organ. Conditions of 
irritation as well as inflammatory processes mighl be expected 
a priori from the mechanical action of the mould. 

After these theoretical conclusions it would be profitable to 



100 DISEASES OF THE STOMACH. 

analyze more closely the cases observed, and to elucidate 
whether the mould formation was in a causative relationship 
to the symptoms of the disease. The decision of this question 
is, however, very difficult, because post hoc is not always ergo 
propter hoc. I have met with the mould formation particularly 
in two groups of gastric affections: first, in cases of intense 
hyperchlorhydria (occasionally attended with hypersecretion 




Fig. 43. — A Blackish Pellicle found in the Wash water of the Stomach (L. C ), in the 

fasting condition. Numerous spore-colonies, mycelia, a few crystals, epithelial cells, and 
several alga? are visible. X 120. 

and vomiting); and, second, in gastralgia with normal or 
reduced gastric secretion. It cannot be denied that in many 
of these cases the mould flakes became smaller in number or 
disappeared after gastric lavage followed by spraying with a 
one to two per mille solution of nitrate of silver. In connection 
with this a subjective improvement could be observed in the 
condition of the patient. Yet it cannot be said with certainty 
that the mould produced the existing pathological process in 



EXAMINATION OF THE IXGESTA. 107 

the stomach: for we find cases analogous in every respect with- 
out the presence of mould fungi. Xot withstanding this, it 
appears plausible that these mould fungi are connected to a 
certain extent with the above-mentioned abnormal conditions; 
and even if they are not the cause of these, they undoubtedly 
increase their severity. 

The occurrence of mould in the stomach in large masses 
must, therefore, be considered of importance from a thera- 
peutic standpoint: hence it must be our endeavor to free the 
stomach from them as soon as possible. This is best done by 
irrigation of the stomach in the fasting state of the patient. 

i $& ■«% «..a* ^ -.>=<■ N *^: < .ta&*N 

Fig. 44.— Group N (Normal). A small piece of gastric mucosa (patient Mrs. H.) present- 
ing a cross-section of the glands in normal appearance. XSO. 

This acts in a purely mechanical manner, since the mould flakes 
are removed with the water. The use of the gastric douche 
might also have a favorable influence in this direction. Follow- 
ing this the application of an antiseptic solution of silver nitrate 
with a spray appears likewise of some utility. Aside from the 
therapeutic measures just described, the treatment of these 
must be directed in accordance with the special disease 
present. 

[d] Small Pieces of Gastric Mucosa. — In washing out the 



108 DISEASES OF THE STOMACH. 

stomach (especially in the fasting condition) occasionally a 
small piece of gastric mucosa may be found in the wash water. 
Such a small piece of gastric mucosa may also be found occa- 
sionally in the gastric contents when examining the patient 
after a test breakfast or test dinner. Boas 1 was the first to 
make use of such specimens for microscopical examination. 
He was of the opinion that such an examination permits one 
to judge of the morbid anatomical condition of the given case. 
A short time afterward I observed that in some cases the 




C3\», 



Fig. 45. — Group C (Connective-Tis3ue Formation). A piece of gastric mucosa (from 
patient Mrs. K. A.) showing beginning atrophy of the glands (small pale areas within the 
glands) and connective-tissue proliferation. X 120. 

occurrence of small pieces of gastric mucosa in the wash water 
is a constant phenomenon. The number of these pieces varies 
from one to four (see Erosions of the Stomach). During the 
last ten years I had the opportunity to examine a great number 
of such small particles of gastric mucosa, a large part of which 
belonged to cases of erosions of the stomach, the remainder 
to many other affections. Such a piece of gastric mucosa looks 
quite red. The thickness may vary from J to 1 mm., while the 

1 J. Boas: L. c, p. 225. 



EXAMINATION OF THE IXGESTA. 109 

size may vary from that of a large pin's head to that of a small 
bean. Sometimes they are found embedded in mucus. 
While the presence of glands in these small pieces may be found 
by examining them in fresh condition under the microscope, 
a thorough examination can be made only after a sufficient 
preparation of these particles (hardening in alcohol, embedding 
in celloidin and staining with eosin, hematoxylin, picro- 
carniine. methylene blue, and thionin). 

In examining the microscopical picture of the different speci- 
mens the following groups can be easily distinguished: 



AMkMtm 





Fig. 46. — Group C (Connective-tissue Formation.) A piece of gastric mucosa (from 
H. R. D.), showing the mouths of glands; the pale spots show beginning atrophy of the 
glands; connective-tisue proliferation best shown in lower part of specimen. X120. 

1. N= Normal: Glands and interglandular tissue exist in 
normal proportions. 

2. C = Connective tissue: While there is a normal proportion 
between glands and interglandular tissue, there is a 
marked proliferation of connective tissue around the 
glands. 

3. P= Proliferation: There is a marked proliferation of glands; 
they are nearer each other and sometimes have an elon- 
gated and curved shape. 



110 
4. 



5. 



DISEASES OF THE STOMACH. 

B = Beginning Atrophy: The glands exist in smaller num- 
bers, and are sometimes also smaller in size; the inter- 
glandular spaces being quite large and filled partly with 
small-cell infiltration partly with connective-tissue for- 
mation. 

A = Atrophy: Complete atrophy; no glands visible only indi- 
cations of their previous existence; round-cell infiltration. 




Fig. 47. — Group P (Proliferation of Glands). A piece of gastric mucosa (from patient 
C. C.), showing proliferation of glands. X80. 

6. V = Vacuolization : Within the glands exist vacuoles of 
different shape, being the result of a mucoid degeneration 
of some glandular cells. 
Sometimes one specimen shows characteristics belonging to 
two of the groups mentioned. 

For the beautiful execution of the drawings I am indebted 
to Dr. C. A. Elsberg, who made them from my specimens (see 
Figs. 39 to 50). Although I think that the microscopical 
examination of these pieces of gastric mucosa is of great interest 



EXAMINATION OF THE IXGESTA. 



Ill 



and may occasionally help to supplement the diagnosis, I do 
not believe that it permits us to judge positively about the 
original affection of the stomach, for in some cases I have 




Fig. 48. — Group B (Beginning Atrophy). A piece of gastric mucosa (from patient 
B. E. with carcinoma cardia?), showing destruction of glands by connective-tissue prolifera- 
tion. X60. 

noticed in the microscopical picture very few small glands, the 
whole field having the appearance of atrophy, and still the 
gastric secretion was perfectly normal. On the other hand, 



<£j 



_ 



"^i#S 






Fig. 40. — Group A ''Atrophy). A piece of gastric mucosa (from patient R. H. D.). 
No glands visible, only some empty spaces where glands had previously existed. X80. 

I 1 had a patient with distinct symptoms of chronic gastric 

] For further details see Max Einhorn: "The State of the Gastric .Mucosa 

in Secretory Disorders of the Stomach," Medical Record, June 27th, 1896; 

Kin weiterer Beitrag zur Kenntniss der Bistologie der Magenschleim- 

haut in pathologischen Zustanden dieses Organs," Deutsche med. Wochen- 

■chr., 1003. No. 13. 



112 



DISEASES OF THE STOMACH. 



catarrh and diminished gastric secretion in whom the pieces 
of gastric mucosa found in the wash water presented a perfectly 
normal appearance (Fig. 37). 

(e) Particles of Tumors. — In the gastric contents obtained 
after test meals, in the vomited matter, in the wash water 
after lavage of the stomach, or within the tube after an explora- 
tory examination, small particles of tissue may be found. 




Fig. 50. — Group V (Vacuolization). A small piece of gastric mucosa (from patient J. 
with carcinoma pylori), showing mucoid degeneration of the glands with vacuolization; 
some connective-tissue proliferation. X140. 

These, if examined under the microscope, may occasionally 
reveal the nature of a tumor, whether cancerous or not. The 
examination is of importance if a characteristic picture of a 
malignant type is discovered. Most frequently such pieces 
may be obtained in cases of cancer of the cardia. I append a 
drawing obtained from a specimen of such a small piece of 



EXAMINATION OF THE IXGESTA. 113 

cancerous tissue from a patient with cancer of the cardia 
(Fig. 51). 

The Value and Limitations of Examinations of the 
Gastric Contents. 

When are examinations of the gastric contents necessary 
and when not? On the whole, I would say that they may 
be omitted whenever we are able to arrive at a positive diag- 
nosis without them, and in all acute conditions, the latter 




Fig. 51. — A Piece of Tumor (from B. E.) Obtained after Examination with Stomach 
Tube. In fresh condition it appeared white and was thicker and firmer than pieces of 
gastric mucosa. Cross-section presents all appearances of alveolar carcinoma. X140. 

generally tending to amelioration in a short while. They are 
further not absolutely necessary in chronic conditions which 
are apparently improving under the established regimen and 
in the majority of purely nervous affections of the stomach. 
In cases in which there is suspicion of an ulcer, the tube should 
be used with utmost care, and, if possible, should be replaced 
by the stomach bucket. In cases of ulcer with hemorrhage 
it is best to forego either the tube or the bucket . Cases with 
symptoms pointing to a certain secretory disorder (as, for 
instance, hyperchlorhydria, gastro-succorrhoea continua peri- 
8 



114 DISEASES OF THE STOMACH. 

odica or chronica) may first be treated without a verifying ex- 
amination of the gastric contents; but if this treatment prove 
unsuccessful, an examination of the gastric contents should be 
made. 

The large field in which these examinations of the gastric 
contents are necessary comprises all chronic affections of the 
stomach, with doubtful diagnosis, that show but slight evi- 
dences of improvement. The examination may help us to 
recognize the following conditions: 

1. Chronic gastric catarrh: Acidity diminished, the fer- 
ments present, free hydrochloric acid variable; mucus present 
in a large number of cases. 

2. Achylia gastrica: Total absence of gastric juice, no 
hydrochloric acid, no ferments, total acidity very low, almost 
neutral. 

3. Cancer of the stomach: In many instances incipient 
cancer of the stomach may be recognized by the constant 
presence of the following symptoms: Free hydrochloric acid 
absent; lactic acid present; acidity not especially low, some- 
times increased; mucus; sometimes small amounts of blackish- 
looking blood, and stagnant food. 

4. Hy perchlorhydria : Free hydrochloric acid present; 
acidity between 70 and 140. 

5. Gastro-succorrhcea continua chronica: Presence of about 
60 to 100 c.c. of clear gastric juice in the stomach in the fasting 
condition. 

G. Erosions of the stomach: Presence of a few small pieces 
of the gastric mucosa in the wash water of the stomach in the 
fasting condition. 

7. Ischochymia: Presence of food in the stomach in the 
fasting condition. 

Often the examination of the vomited matter may do away 
with the need of obtaining the gastric contents by artificial 
means. It is, however, readily understood that the vomited 



OTHER FUNCTIONS OF THE STOMACH. 115 

matter may occasionally fail to furnish exact data in regard to 
the condition of the gastric secretion, as it is mixed with 
mucus from the oesophageal walls and the mouth. 

AVliile the results of examinations of the stomach contents 
are useful in aiding to establish the diagnosis in gastric dis- 
orders, it is hardly necessary to say that we should not rely upon 
them alone. "We must always combine all the data concerning 
any given case at hand before arriving at a conclusion. It is 
only in this way that these examinations will be of great 
service to us in helping us to establish a more positive diagnosis 
and in thus facilitating the treatment. 

Other Functions of the Stomach. 
1. The Absorptive Function of the Stomach. 

The absorptive function of the stomach is as a rule tested 
by Penzoldt and FaberV method. One to two decigrams of 
potassium iodide are administered in a gelatin capsule and the 
saliva is examined every minute or two for the presence of 
iodine. This is done in the following maner: 

Strips of starch paper (filter paper satured with a starch 
solution and dried) are moistened with the saliva of the patient 
and then a drop of fuming nitric acid is added. The presence 
of iodine gives to the starch paper a slightly violet or blue 
color. Under normal conditions, it takes as a rule eight to 
fifteen minutes until the appearance of this reaction in the 
saliva. 

Herschell 2 described another method of estimating the 

ptive power by means of a capsule containing 2 decigm. 

of powdered rhubarb. If the stomach be normal, this 

'Penzoldt und Faber: "Ueber die Resorptionsfahigkeit dor mensch- 
fiehen Mn^-n-ohleinhaut und ihre diagnostische Verwerthung." BerL 
klin. Wochenschr., 1882. 

'.Herschell: "Indigestion," London, 1895, p. 115. 



1 1 6 DISEASES OF THE STOMACH. 

should appear in the urine in fifteen minutes and will give a 
red color with liquor potassa3. 

According to my experience, the absorptive faculty of the 
stomach should always be examined under similar conditions, 
as the results will differ materially whether the test is made in 
the fasting condition or when the stomach is full. It seems to 
me that in many instances several writers have not laid much 
stress upon this point, and in this way have come to wrong 
conclusions. 

2. Motor Function of the Stomach. 

Under motor function, as a rule, is understood the peristalsis 
of the stomach and the motion of the ingesta caused thereby 
within the organ, as well as the transportation of the food 
from the stomach into the intestines. I prefer, however, to 
distinguish that function which serves the purpose of expelling 
the gastric contents (prochoresis) 1 from the merely mechanical 
motions to which the ingesta are subjected within the organ 
(anakinesis). 2 This latter function we shall describe later on 
under the heading of mechanical function. 

1. Leube's Method. — The oldest method of ascertaining the 
condition of the motor function of the stomach is that first 
devised by Leube. 3 It consists in washing out the stomach 
six to seven hours after a large meal (dinner). Normally the 
stomach is found empty at that time — that is to say, all the 
food has already left the organ. Where large quantities of 
food are still found, it shows that the motor function is retarded. 
Washing out the stomach two to three hours after a smaller 
meal, like Ewald's test breakfast, may serve the same purpose, 
for normally the stomach is then found empty. 

1 ij irpoyuprjo-is, the advancing. 

2 r\ avaKLv-qais, the shaking. 

3 Leube: "Krankheiten des Magens und Darms." Ziemssen's "Hand- 
buch der spec. Path, und Therap.," Bd. 17, 2te Halfte. 



OTHER FUNCTIONS OF THE STOMACH. 117 

2. Ewald and Siever's Method. — Ewald and Sievers 1 have 
devised another, so to speak, clinical test, for the motor faculty 
of the stomach. The principle of the test consists in the prop- 
erty of salol, which is a compound of phenol and salicylic acid, 
of not being decomposed in acid solutions. In relatively 
feeble alkaline fluids salol is decomposed into salicylic acid 
and phenol and then absorbed. The gastric contents always 
being acid, the salol will not undergo any changes there. 
After leaving the stomach, however, and coming in contact 
with the intestinal juices which are alkaline, it is quickly split 
up into its two components. The salicylic acid is then absorbed 
by the blood and eliminated through urine as salicyluric acid. 
The latter is easily recognized in the urine by the violet color 
produced on the addition of neutral ferric-chloride solution. 

The salol test is made as follows: The patient takes 1 gm. 
salol in two gelatinous capsules half an hour after a slight meal. 
Before the ingestion of the capsules he empties his bladder, 
and then urinates every half-hour for about two hours. All 
the different specimens of urine are then examined with ferric 
chloride solution, and it must be ascertained in which speci- 
men the violet color begins to appear. Normally it requires 
about an hour until the appearance of salicyluric acid in the 
urine; while in case of retarded motion of the stomach it takes 
two horns and even longer. In order to detect the earliest 
trace of salicyluric acid, Ewald first advised treating the urine 
with ether and then making the test in the ethereal residue. 
Afterward Ewald and I 2 suggested a simpler method which 
permitted us to dispense with the ether. This consists in 
moistening a piece of filter paper with urine, and then placing 
a drop of ferric chloride solution by means of a glass rod upon 

1 Ewald und Siovors: "Zur Pathologic und Therapie <\<>t Magenectasien." 
Therap. Monatshefte, August, 1887. 

raid und Einhorn: " Verhandlung. des Vereina f. innere Medicin," 
1888, .. 58. M . Einhorn: "Die neueren MethodeE der Magenunter- 
suchung." New Yorker mediz. Monatschr., M.-.rz, 1889. 



118 DISEASES OF THE STOMACH. 

the middle of the moistened paper. The edges of the drop will 
assume a violet color in the presence of even the smallest 
trace of salicyluric acid. These papers may be dried and 
preserved and in this way one can easily compare the reactions 
of the urine in the same patient at various times. 

Huberts Modification. — Although normally, as a rule, the 
salicyluric acid appears in the urine about one hour after the 
ingestion of the salol, there are exceptions in which even in 
healthy people the reaction is greatly retarded. For this 
reason Huber 1 suggested to determine the length of time 
required for the complete disappearance of the reaction in the 
urine; for it is readily understood that the longer the time 
required for the salol to be absorbed and entirely eliminated 
through the urine the longer it has remained within the stomach. 
When the urine gives no reaction whatever, it shows that the 
whole amount of salol has long since left the stomach, and has 
been eliminated from the organism. In case of retarded 
motion of the stomach, parts of the salol remain and leave 
this organ only after a very long time. In this way the reac- 
tion of the salicyluric acid will extend oyer a prolonged period. 
Huber found that normally the excretion of the salicyluric 
acid after 1 gm. of salol lasted twenty-four hours; in patients 
with enfeeblement of the motor function of the stomach it 
lasted forty-eight hours or even longer. 

The salol test, as suggested by Ewald or as modified by 
Huber, certainly gives a clew as to the condition of the motor 
function of the organ and is clinically of value, although either 
of them is by no means absolutely reliable. 

S. Heichelheim 2 made use for the same purpose of iodipin, 
which is not decomposed in the stomach. He administers 1.6 
gm. of iodipin in gelatin capsules at breakfast. The saliva is 

1 Huber: "Die Methoden zur Bestimmung der motorischen Thatigkeit 
den Magens." Correspondenzbl. f. Schweiz. Aerzte, 1890. 
2 S. Heichelheim: Zeitschr. fur klin. Med., 1900, p. 321. 



OTHER FUNCTIONS OF THE STOMACH. 119 

then examined every fifteen minutes for the presence of iodine 
(by means of starch paper and fuming nitric acid). In 
most instances the reaction appears before the end of an hour. 
In pyloric obstruction it is greatly retarded. 

3. Klemperer s Oil Test. — Oil is not absorbed by the stomach 
wall. If, therefore, a certain quantity of oil be ingested and 
the stomach emptied after a certain period, it will be possible 
to judge from the amount of oil withdrawn the state of the 
motor faculty; for the greater the quantity of oil recovered the 
less has left the organ. Klemperer 1 proceeds as follows: After 
washing out the stomach, he pours about 100 c.c. of pure olive 
oil into the empty organ. Two hours later the stomach is 
aspirated and whatever oil is left removed as thoroughly as 
possible. The difference between the original quantity of oil 
and that withdrawn indicates the state of the motor function 
of the stomach. According to Klemperer, normally at this time 
only 20 to 40 c.c. of the oil ought to be found. This method, 
however, is complicated and to some objectionable; and as the 
results obtained by it do not allow more conclusions than the 
method of Leube, it has not come into extensive practical use. 

4. Examination of the Stomach in the Fasting Condition. — 
The best and easiest way to test the motor function of the 
stomach is to examine this organ, by means of the tube and 
lavage, in the morning in the fasting condition after the inges- 
tion of a substantial supper on the night previous. Normally 
the stomach is empty, and therefore when the organ is found 
to contain a quantity of food, this is the best sign of retarded 
motion. This method is practically used by most writers. 

Mechanical Function. 

Under the mechanical function of the stomach we under- 
stand those changes which arise in the physical condition of 

1 Klemperer: "Ueber die motorische Th&tigkeil dea menschlichen 
Magen.s. -? Deutsche med. Wochenschr., 1888, No. 17. 



120 



DISEASES OF THE STOMACH. 



foods and are produced by motions of this orran. These 
motions are of two characters: (1) active (peristaltic) and 
(2) passive (transmitted, respiratory, and pulsatory). Both 
motions shake the contents of the stomach and cause all parts 
of the food to come into direct contact with the gastric 
mucosa. 

The Gastrograph. — Until recently there was no way of ascer- 
taining this mechanical function of the stomach in the living. 
All the experiments made with regard to this subject have 
been performed on laparotomized animals. These, however, 
scarcely permitted any conclusions as to the manner in which 
peristalsis of the stomach normally takes place; for animals 
prepared for such experiments (after being chloroformed or 
etherized) are certainly not normal. 

As the mechanical action consists in the churning of the 




Fig. 52. — The Ball Apparatus of the Gastrograph (Einhom). Natural size. 



contents, and as by estimating the latter we may determine 
the first, I have constructed an apparatus which indicates 
every motion to which it may be subjected. The whole 
apparatus comprises: 1. The ball (being the principal part) 
2. A few electric cells. 3. The ticker. 

The ball (Fig. 52) consists of two hollow metallic hemis- 
pheres (a), which are screwed together; within it is lodged and 
attached to the upper hemisphere, but perfectly insulated 
from the same at the attachment, another ball provided with 
spikes (b) radiating in all directions, but not touching the 
inside walls of the hemispheres; another very small platinum 



OTHER FUNCTIONS OF THE STOMACH 



121 



ball (c) lies within the large ball and can freely move in all 
directions, knocking at the spikes (see Fig. 53). Two insu- 
lated wires — one connected with the hollow ball, the other 
with the spike ball — are encased in a very fine, thin rubber 
tube, forming the cable, and separate at the end into two 
branches, which must be attached to an electric battery. As 
soon as the platinum ball touches one of the spikes an electric 
circuit is made; when, however, the platinum ball moves a 




?ion of the Ball, showing its Interior Construction. Enlarged throe 
and a half times, a, The two hemispheres: b, the spiked ball; c, the platinum ball. 



little way and ccaso< to touch the spike the current Is broken. 
At each motion of the ball apparatus a rolling of the little 
platinum ball takes place and the electric currenl is either 
closed or broken. When the apparatus is at rest there is no 
change in the current. On connecting the "ticker" with the 
ry and the ball, each motion of the latter will be recorded 



122 



DISEASES OF THE STOMACH. 



on the paper in showing the "breaks" and "makes" of the 
current. 

If the ball is swallowed and brought into the stomach, the 
motions of the former — which are caused by the active and 




Fig. 5-4. — A Patient Undergoing Examination with the Gastrograph. 

passive motions of the stomach — can be recorded in the way- 
described. 

I have called this apparatus "gastrokinesograph," or, 
shorter, "gastrograph." 1 

From numerous tests which I have made, it appears with 

1 The gastrograph may be obtained of Richard Kny & Co., New York. 



OTHER FUNCTIONS OF THE STOMACH. 123 

certainty that the gastrograph works in the desired manner — 
i.e., it indicates the motions of the ball and can thus be utilized 
for the valuation of the motions of the stomach or the mechani- 
cal action of this organ. 

Method. — The ball is dipped in lukewarm water, introduced 
into the pharynx of the patient, and the latter told to swallow. 
The patient may drink some water. After a short while (from 
a minute to a minute and a half) the ball reaches the stomach. 
It is advisable to let the ball slip far down into the stomach, so 
that the distance from the mouth to the ball (length of cable) 
is about 50 cm. The cable is then connected with the battery 
and the indicator and the latter set agoing for three minutes 
(Fig. 54). The patient during this procedure sits quietly on 
a comfortable chair. At the end of three minutes the indi- 
cator is checked, the cable disconnected from the battery, 
and the ball withdrawn from the stomach. When at the 
introitus oesophagi, it is necessary, here in the same way as 
when using the bucket 1 or the cleglutible electrode, to have 
the patient swallow, and to utilize the moment when the 
larynx goes upward and forward, to withdraw the ball without 
using any force whatever. 

The strip of paper which has rolled off from the reel is cut off 
and the marks then perused. The black line shows when the 
current was closed, the empty places when there was no current. 
A- an instance I give a few gastrograms (reduced ten times) 
(Fig. bo). It is practical to enter the marks of the strips into 
a copy-book. This is done in the following way: Each line 
i- divided into three equal spaces — each space corresponding 
to one minute — each space (or minute) into ten divisions, and 
ffae "breaks" and "makes" of the current marked with dot- at 
the corresponding place. In this way the number of current 
changes can very easily be looked over and comparisons made. 

1 Max Einhorn, Medical Record, July L9th, 1890. 



124 DISEASES OF THE STOMACH. 

(a) Physiological. — I have made several tests with the 
gastrograph on healthy people. 

The experiments show that the stomach is not so inactive 
mechanically as several authors believed, and that it churns 
the contents almost continuously with slight periodical inter- 
ruptions. • 

The number of motions for three minutes averaged from four 
to forty-one. 

When fasting, the mechanical action of the stomach seems 
to be much less than after' meals. 

(6) Pathological. — Most patients have been examined with 
the gastrograph either when fasting or from an hour to an hour 
and a half after the test breakfast, taking about half a glassful 
of water when swallowing the ball; many of the patients have 
been examined under both conditions on different days. Some 
jo. 

hn.A.R. _ == ~ 

Fdvr. C.A. 



Fig. 55. — Three Gastrograms Obtained from Patients H. R., Dr. A. R., and Edw. C. A. 

of them have been subjected to a very great number of tests, 
in order to ascertain whether there is a certain constancy in 
the results. The whole number of patients examined was 
twenty-seven, the number of tests sixty-four. 

In perusing the gastrograms obtained from my patients and 
comparing them with those obtained from healthy people, 
there are three different classes among them. One corre- 
sponds to the normal; the second class is marked with too much 
mechanical action, the number of dots being greatly increased; 
the third class shows a remarkable slowness and sluggishness of 
the mechanical function, the number of dots being reduced to 
\. 3, or 0. 

Hemmeter-Moritz's Method. — As the gastrograph does not 
permit of a distinction between the active and passive motions 



OTHER FUNCTIONS OF THE STOMACH. 125 

of the stomach. Dr. J. C. Hemmeter, 1 of Baltimore, has recently 
devised another method for testing the gastric peristalsis. The 
essential part of the apparatus is a deglutible elastic stomach- 
shaped bag of very thin rubber and attached to an oesophageal 
tube. The stomach-shaped pouch has the shape of the stomach 
only when it is blown up. It does not occupy much space 
when it is collapsed and can be introduced without difficulty 
into the stomach of patients. The oesophageal tube may be 
very small, not quite half the size of the ordinary tube used 
in lavage. When the bag has reached the stomach, which 
can be determined by a mark previously made on the tube, it 
is filled with ah' and connected either with a water manometer or 
tambour on the Ludwig kymograph. The slightest contraction 
of the involuntary fibres of the gastric muscle layer will com- 
press the very elastic intragastric bag and distend the tambour, 
to which a glass bulb ink pen is attached, recording the gastric 
peristalsis as the clockwork moves the paper along. On the 
upper margin of the kymographion paper a record pen con- 
nected with a chronometer indicates seconds on the record by 
small dots, so that it is possible to determine the time of occur- 
rence and duration of the gastric peristalsis. As the stomach 
perceptibly moves with every inspiration and expiration, a 
pneumograph is tied around the patient's waist recording 
every respiratory movement on the kymograph. It will be 
: i on the tracing that many movements of the pen connected 
with the intragastric bag are passive and caused by the act of 
respiration, but there are other very high and long excursions 
of the gastric pen which are independent of the movement of 
the pneumograph^ pen, or occur when respiration is suspended 
for a short while. These are the muscular contractions proper 
of the stomach. The same method has been independently 
used and described by Moritz, of Munich. 

1 J. C. Hemmeter: New York MeJical Journal, June 22d, 1805. 



120 DISEASES OF THE STOMACH. 

In his paper Hcmmeter says: "In making studies on the 
kymograph on the gastric motility, only such patients are 
taken as have become accustomed to the stomach tube, as the 
nausea and vomiting first attending the initial introduction of 
the tube make an exact record impossible." 

This sentence shows that this apparatus cannot be applied 
without difficulty and for this reason appears unsuitable for 
practical purposes. Although the gastrograph does not permit 
a distinction between the active and passive movements, it 
affords, nevertheless, an accurate idea as to the mechanical 
action as such, for the passive movements certainly also partici- 
pate in this function of the stomach and should not be ignored. 
In this way I think that the gastrograph method, not being so 
complicated and being easily performed, presents many 
advantages over Hemmeter's apparatus. 

Recently the z-rays have been successfully used for the study 
of the peristalsis of the stomach. 



CHAPTER III. 

DIET. 

Dietetics comprises the study of nutrition in health and 
disease and of the substances serving for this purpose (the diet). 
All living organisms derive then nourishment from the vege- 
table kingdom, either directly, or indirectly by living upon 
animals which in turn live upon a vegetable diet. Foods are 
substances which are required for the nutrition and mainte- 
nance of the body; they replace its wastes and losses. 

In studying the normal nutrition of man we perceive quickly 
that there is a great variety in the food of healthy persons with 
regard to the quantity as well as to the different food substances. 
Nevertheless, they all contain the three groups of food-stuffs: 
Albumin, carbohydrates, and fats. Thus, for instance, vege- 
tarians live and thrive principally on vegetables; the Esquimaux, 
on the other hand, almost exclusively on animal diet. The 
golden path, however, lies intermediate, and all authors (Voit, 
Pettenkofer, Hoffmann, Forster, and Gruber) recommend a 
combination of animal and vegetable food. R. Virchow like- 
wise is of the same opinion, and expresses himself regarding 
this question as follows: "Although the Kirghez and Esqui- 
maux show us that health and life can exist through many 
generations on an exclusively nitrogenous diet — other tribes 
(Hindoos) live principally on non-nitrogenous food — still 
history shows us that the highest attainments of the human 
race have emanated from nations who have lived and live on 
mixed diet." A mixed diet, taken partly from the vegetable 
and partly from the animal kingdom, is the most suitable form 
of nourishment. We obtain the greatest amount of carbo- 

]_>7 



L28 DISEASES OF THE STOMACH. 

hydrates from the vegetable kingdom, while a great deal of the 
albumin is derived from animal food. The relation between 
animal and plant albumin, according to Munk and Uffelmann, 1 
should not be less than three to seven. As regards the quantity 
of food, according to the same authors, an adult doing a medium 
amount of work requires daily 118 gm. albumin, 56 gm. fat, and 
500 gm. carbohydrates. 

Food only in small portions serves the purpose of recon- 
structing tissue waste; in its largest part, however, it is used 
for generating the heat requisite for the maintenance of life. 
For this reason it is customary to speak of the necessary amount 
of heat units during twenty-four hours instead of the quantity 
of food. By "heat unit" is meant, as is well known, that 
quantity of heat which is required to raise the temperature 
of 1 gm. of water 1° C. "Great heat unit" means the amount 
of heat required for warming 1,000 gm. of water 1° C. Each 
kind of food is ultimately oxidized in the body to its end pro- 
ducts, and is in greatest part exhaled in the form of carbonic 
acid; the more carbon atoms a food-stuff contains the more 
heat units it will generate. In speaking of the heat value of 
food, the great heat units are used, the term "great," however, 
being omitted. Thus 1 gm. of albumin generates 4.1, 1 gm. 
of fat 9.3, and 1 gm. of carbohydrate 4.1 heat units. If we 
know the quantity of nourishment taken, the amount of the 
introduced heat units is easily determined by multiplying the 
different food-stuffs by the above-given figures. The daily 
amount of heat generated by the body, or necessary for the 
maintenance of the same, has been approximately estimated at 
twenty-five hundred heat units. 2 The heat value of the food 
taken by an average working person amounts, according to 



1 Munk und Uffelmann: "Die Ernahrung des gesunden und kranken 
Menschen," Wien, 1887. 

- Koenig: "Die menschlichen Nahrungs- und Genussmittel," Berlin, 
1883, p. 53. 



DIET. 



129 



von Xoorden, 1 to about forty heat units when working, and when 
resting to about thirty-four heat units per kilogram a day. 

The following table of the composition of the different foods 
and the amount of heat units they produce will make it easy to 
figure out whether a certain known quantity of taken nourish- 
ment is sufficient to maintain the bodv in balance or not. 



COMPOSITION OF THE MOST COMMON FOOD SUBSTANCES. 
I. Dairy Products. 



Albumin, Fat, Carbohydrate, Calories, 

per cent. per cent. per cent. per 100. 



Cows's milk 4.0 to 4.3 3.0 to 3.8 



Cream 

Butter 

Whey 

Buttermilk. 



Kumyss (of cow's milk) 



Cheese cream) 

Cheese 

Egg 



3.61 
0.5 
0.5 
3.0 



3.35 



25.0 
33.0 
12.5 



26.75 

90.0 

0.3 

1.3 



2.0; 



30.0 

9.0 

12.0 



3.7 

3.52 

0.5 

3.6 

3.0 
0.7 lactic 
acid 

1 . 9 alcohol 
. 8 carbonic 
acid 

3.0 

5.0 

0.5 



64 
276.01 

837 

3.67 



32.90 



394 
240 
165 



Von Xoorden: Berliner Klinik, Heft 



130 



DISEASES OF THE STOMACH. 



II. Meats and Game. 



Beef (fat) 

Beef (lean) 

Veal (fat) 

Veal (lean) 

Mutton (very fat) . . 
Mutton (leaner) .... 

Pork (fat) 

Pork (lean) 

Ham (Westphalian) 

Sweetbread 

Pulverized meat. . . . 

Poultry 

Spring chicken 

Duck (wild) 

Squab 

Game 

Hare 

Venison 



Albumin, 
per cent. 



17.19 

20.78 

18.88 

19.84 

14.80 

17.11 

14.54 

20.25 

23.97 

22.0 

64.5 

22.0 

18.49 

22.65 

22.14 

23.0 

23 . 34 

19.77 



Fat, 
per cent. 



Carbohydrate, 
per cent. 



26.38 
1.50 
7.41 
0.82 

36.39 
5.77 

37.34 
6.81 

36.48 
0.4 
5.24 
1.0 
9.34 
3.11 
1.00 
1.0 
1.13 
1.92 



0.07 
0.05 



1.50 

2.28 



1.20 
2.33 

0.76 



0.19 
1.42 



Calories, 
per 100. 



315.81 

99.15 

146.61 

86.97 

399.31 

123.81 

406.88 

146.36 

453.69 

93.92 

322.53 

100 

167.59 
131.36 
100.07 
103.60 
107.08 
105.44 



III. Fish. 





Albumin, 
per cent. 


Fat, 
per cent. 


Carbohydrate, 
per cent. 


Calories, 
per 100. 


Pike 


18.5 
20.61 
17.09 
15.01 
22.30 
4.95 
19.5 
28.04 


0.5 
1.09 
9.34 
6.42 
2.21 
0.37 
17.0 
16.26 


0.75 


83.57 


Carp 


94.64 


Shellfish 




156.93 


Salmon 

Sardellen 

Oysters 

Salt herring 

Caviar 


2.85 
0.45 


132.93 
113.83 
24 


0.5 

7.82 


240.55 
298.24 







DIET. 

IV. Cereals axd Vegetables. 



131 



Albumin, 
per cent. 



Fat, Carbohydrate, Calories, 
per cent. per cent. per 100. 



Sago 0.5 

Wheat flour ; 8.5 

Rye flour 10.0 

Wheaten bread 6.0 

Rye bread 4.5 

Roll ! 6.82 

Zwieback 9.5 

Cauliflower 2.0 to 5 

Carrots 1.04 

Asparagus 2.0 

Rice 5.5 

Beans 19.5 

Peas 19.5 

Potatoes 1.5 

Oatmeal 12.5 

Barley meal 8.31 

Spinach 3.49 

Pickles 1.02 



traces 



25 


75 


77 

4 
21 



0.3 
1.5 
2.0 
2.0 



5.26 
0.81 
0.58 
0.09 



86.5 

73.0 

69.0 

52.0 

46.0 

43.72 

75.0 

4.0 

6.74 

2.5 

76.0 

52.0 

54.0 

20.0 

66.77 

75.19 

4.44 

0.95 



356.70 

345.78 

342 . 50 

245 

216 

213.87 

356 

35 

33.85 

21 
348.10 
311.75 
319.95 

88 
338.80 
323 

38 



V. Soups axd Beverages. 




Carbohydrate, Calories, 
per cent. per 100. 



Milk soup with wheat 5.0 

flour. 

Meat broth (ordinary).. . 0.4 

Meat juice (pressed) .... 6.0 to 7.0 

Beef tea 0.5 

f 9.0toll.O 

Leube's meat solution. ! albumin 

f 1.79 to 6.5 
peptone 

Malt extract 8.0 to 10.0 

Barley soup 1.5 

pap with milk 8.8 

Coffee 3.12 

Tea 12.38 

Beer 0.5 

Porter 0.7 



15.0 



112 



55.0 
11.0 
28.6 



. 3 
. 3 



258.30 

60.96 
182.61 



60 



132 



DISEASES OF THE STOMACH. 
VI. Fruits. 





Free acid, 
per cent. 


Albumin, 
per cent. 


Fat, 
per cent. 


Carbohydrate, 
per cent. 


Apples 

Pears 

Plums 

Peaches 

Grapes 

Strawberries 


0.82 
0.20 
1.50 
0.92 
0.79 
0.93 



0.36 
0.36 
0.40 
0.65 
0.59 
0.54 
5.48 




0.45 
1.37 


7.22 
3.54 
4.68 
7.17 
1.96 
1.01 


Chestnuts 

Sugar cane 


38.34 
3.40 


Honev 




1.20 




5 28 


' 







According to K. Vierordt 1 an adult takes in form of food a 
daily average of 120 gm. albumin, 90 gm. fat, 330 gm. carbo- 
hydrate (the relation of the nitrogenous food-stuffs to the non- 
nitrogenous being 1 to 4), and 2,818 gm. of water. The above- 
mentioned figures differ from those given by F. Hirschfeld. 2 
This author considers 80 gm. of albumin as the lowest amount 
contained in a sufficient diet. Some experiments which I 3 
have made in order to determine the amount of nourishment 
taken by myself during the summer showed figures which 
resembled those of Hirschfeld. The quantity of albumin was 
79.39, fat 54.3 and carbohydrate 263.9; the total of heat- 
units equalled 1,912.5. The amount of heat-units per kilo- 
gramme a day was 32.2. Victuals are composed mostly of 
all the three food groups (albumin, carbohydrate, fat) and 
water, and contain in minute amounts the inorganic salts 
found in the body. 

We are accustomed to speak of easily digestible foods, and 

1 K. Vierordt: "Grundriss der Physiologie des Menschen," 1887, 3 Auflage, 
pp. 288, 289. 

2 F. Hirschfeld: Berliner klin. Wochenschr., 1893, No. 14. 

a Max Einhorn: "Dietetics in Diseases of the Stomach." Medical Record, 
June 24th, 1893. 



DIET. 133 

those difficult of digestion. The term of easily or less digesti- 
ble cannot, however, be explained without some qualifications. 
Many writers judge the digestibility of foods by the length of 
time they require for their digestion in the stomach. Penzoldt 1 
has lately made many investigations with regard to the sojourn 
of food in the stomach in health. He. however, lays stress on 
the distinction between gastric and intestinal digestibility, the 
former being recognized by the length of time the food remains 
in the stomach, the latter being measured by its more or loss 
complete utilization or assimilation, that is, the amount of 
residue excreted with the fa?ces. In giving a list of the digesti- 
bility of different foods I follow Penzoldt's views. 

A. Animal Foods. 

These comprise besides the flesh (muscles) of the different 
mammals, birds, and fishes several other portions of their 
bodies, as, for instance, various glands, brain, lung, liver, etc. 
Oysters and lobsters also belong to this group. In most 
instances the digestibility of this group of foods corresponds 
to their richness in fat. The less fat they contain the more 
digestible they are. Thus we have the following list of animal 
foods classified according to their digestibility: 

Fat, 

per cent. 

-weetbread. veal, cod-fish. pike, oysters 0.4 to 1 

Beef, hare, spring chicken, pigeon, partridge, carp 1 to 1 ', 

Mutton, pork 5 to 7 

i\iar, herring, salmon, eel over 8 

The digestibility of food is greatly dependent on its quality 
and preparation. Young animals have soft and tender meat, 
whereas the flesh of old ones is tough. The different portions 
of the body vary also frequently in their digestibility. The 

1 Pensoldt und Stinzing: "Handbuch der speciellen Therapie innerer 
Krankheiten," Jena, 1895. 



134 DISEASES OF THE STOMACH. 

time that has passed since the killing of the animal is also of 
importance. Fresh meat which is yet in its rigid state is 
tough and therefore very indigestible. In the preparation of 
the meat we must see that it is separated from all indigestible 
matter (fascia, tendons, cartilage). By pounding the meat 
the connective tissue surrounding the muscle fibre is torn. 
By chopping, scraping, or grinding the meat, its digestibility 
is increased. All other methods of preparing meat serve to 
improve its taste. For, according to Penzoldt, raw meat is 
more easily digested than that which has been boiled, broiled, 
or fried. The application of heat also diminishes the danger 
of infection, as many micro-organisms are destroyed by it. 

Eggs are especially rich in albumin and fat. According to 
Penzoldt, soft-boiled eggs (three minutes in boiling water) are 
easiest to digest. Then come raw eggs and scrambled eggs, 
while hard-boiled eggs and omelet souffle are difficult of 
digestion. (Soft-boiled eggs remain in the stomach one and 
three-quarter hours, hard-boiled, three hours) . 

Milk is intended as the sole food of young animals and as 
such contains all the elements of a typical diet : (1) Albuminous 
substances in the form of casein and serum albumin; (2) fats in 
cream; (3) carbohydrates in the form of lactose or milk sugar; 
(4) salts, chiefly calcium phosphate; and (5) water. Milk does 
not stay in the stomach much longer than plain water and 
must therefore be considered very digestible. 

Several articles of food are obtained from milk : 

(a) Cheese, which is the casein precipitated with more or less 
fat, according as the cheese is made of skimmed milk (skim 
cheese), or fresh milk with its cream (Cheddar and Cheshire), 
or fresh milk plus cream (Stilton and Double Gloucester). 
The precipitated casein is allowed to ripen, by which process 
some of the albumin is split up with formation of fat. 

(b) Cream consists of the fatty globules encased in casein 
and which, being of lowest specific gravity, rise to the surface. 



DIET. 135 

(c) Butter or the fatty matter deprived of its casein envelope 
by the process of churning. 

(d) Buttermilk is the fluid obtained from cream after butter 
lias been formed. It is therefore very rich in nitrogen. 

(e) Whey is the fluid which remains after the precipitation of 
casein. It contains sugar, salt, and a small quantity of 
albumin. 

B. Vegetable Foods. 

All of these contain more or less carbohydrates, and the 
principal amount of carbohydrates of our diet is obtained from 
them. 

1. Foods rich in proteids. Leguminous foods (peas, beans, 
lentils, etc.) contain a nitrogenous substance called legumin, 
which is allied to albumin, in the proportion of twenty-five per 
cent. They form a chief source of the nitrogen of the food of 
vegetarians. 

2. Foods rich in carbohydrates: 

(a) Cereals. Bread made from the ground grain obtained 
from various so-called cereals, namely, wheat, rye, maize, 
barley, rice, oats, etc., is the direct form in which the carbo- 
hydrate is supplied in an ordinary diet. Besides starch it 
contains gluten, a nitrogenous body, and a small amount of fat. 
White bread is easier to digest than brown bread. Various 
articles are made from flour: sago, macaroni, biscuits. 

{b) Vegetables (rice, potatoes). They contain chiefly starch 
and sugar. 

(c) Green vegetables (cauliflower, asparagus, turnips, cab- 
bage, carrots, spinach, string beans) are especially rich in salts. 

Almost all vegetables are not eaten in their raw state, but 
after being cooked. The cooking produces the necessary effect 
of rendering them softer so that they can be more readily 
broken up in the mouth. It also causes the starch grains to 
swell up and burst and so aids the digestive fluids in penetrating 



136 DISEASES OF THE STOMACH. 

into their substance. The albuminous matter is coagulated and 
the gummy, saccharine, and saline matters are removed. The 
conversion of flour into dough is effected by mixing it with 
water and adding a little salt and a certain amount of yeast. 
It is by the growth of the yeast which lives upon the sugar 
produced from the starch of the flour that a quantity of car- 
bonic-acid gas and alcohol is formed. By means of the former 
the dough rises. By the action of heat during baking the 
dough continues to expand, and the gluten being coagulated, 
the bread sets as a permanently vesiculated mass. 

(d) Fruit (pears, apples, etc.). They all contain sugar and 
organic acids like tartaric, malic, citric, and others. 

C. Liquid Foods. 

Water is consumed alone or together with certain other 
substances added for flavoring purposes, tea, coffee, etc. 

Tea in moderation is a stimulant and contains an aromatic 
oil to which it owes its peculiar aroma, an astringent of the nature 
of tannin, and an alkaloid, theine. The composition of coffee 
is very similar to that of tea. Cacao, in addition to similar 
substances contained in tea and coffee, contains fats, albumin- 
ous matter, and starch, and must be looked upon more as a 
food. 

Beer in various forms is an infusion of malt (barley which 
has been sprouted and the starch of which is converted in great 
part into sugar) boiled with hops and allowed to ferment. It 
contains from one to eight per cent, of alcohol. 

Cider is the fermented juice of apples; wine the fermented 
juice of grapes and contains from six or seven (Rhine wine and 
white and red Bordeaux) to twenty-four per cent. (Ports and 
Sherries) of alcohol. Spirits obtained from the distillation of 
fermented liquors contain upward of forty to seventy per cent, 
of absolute alcohol. 



DIET. 137 

Utilization of Food. 

The amount of utilization of the food by the digestive tract 
has been studied by Rubner, and according to his investiga- 
tions the residues of the different food-stuffs, that is, the indi- 
gestible matter, are least under a diet of animal food and 
highest under one consisting of vegetables. He gave the fol- 
lowing scale: Meat, eggs, macaroni, white bread, milk, rice, 
maize, carrots, cabbage, potatoes, brown bread. 

Diet in Health. 

The diet in health should not always comprise the most easily 
digestible substances. For by so doing we weaken our diges- 
tive system. Although it is not necessary always to choose the 
substances which are hard to digest, it is certainly not neces- 
sary to avoid them. The food should consist of mixed substances 
(easy and difficult to digest) and should always present a 
sufficient variety. As to the distribution of meals and also as 
to the predominance of the different food articles in diet it is 
impossible to give the same rule for all. Good use and custom 
are the best and most important guides. 

A Few Hints with Regard to the Proper Way of Eating. 1 

Euphagia. — Like all natural processes, the partaking of food, 
if done in a correct manner, affords the body pleasure and 
satisfaction. For this purpose, however, the organism must 
be prepared by previous work and subsequent rest. Already 
in the Bible the following quotation is found: "In the sweat of 
thy brow shalt thou eat bread." This shows the importance 
of work on eating. A similar proverb exists in the German 
ige: "Arbeit macht das Leben suss." (Work sweetens 

! Max Einhorn: "The Art of Eating Properly (Euphagia) and the Barm 
og too Rapidly and too Slowly (Tachyphagia and Brady phagia)," 

i\ Record, January 7th, 1905. 



138 DISEASES OF THE STOMACH. 

life), which sentence naturally refers not only to eating, but to 
all functions of life. Granted, however, that work is necessary, 
yet it must not be in excess or lead to exhaustion, as in this 
condition the appetite usually disappears and digestion becomes 
sluggish. 

Meals are best taken during those periods when the body is 
at rest. The time for taking food must not be too short. 
During the meal it is better not to think of business, or serious, 
or, perhaps j even sad things. Our whole and undivided atten- 
tion should be given to our meals. Pleasant company, light 
conversation, jokes, and stories add to the enjoyment of food. 

It is generally known what a powerful influence the brain 
exerts over our digestive faculties. Great grief robs us of our 
appetite and may cause real disturbances of digestion. Paw- 
low has lately established the physiological importance of the 
mental state of digestion, having shown, for instance, that 
delicacies produce secretion of gastric juice as soon as they are 
perceived by the eye, even before they are eaten. 

The food must not only be palatable, but must be served in 
an attractive manner (fine dishes, table decorations, etc.). 

In eating we must take time to chew our food thoroughly. 
This serves a double purpose: (1) Through the act of mastica- 
tion the coarser particles of food are broken up; (2) more saliva 
is secreted and is thoroughly mixed with the food. The diges- 
tion of starch is thus materially aided, and the proteids are 
made more easily accessible to the action of the gastric juice. 

Water should accompany each meal. It increases the appe- 
tite and the enjoyment of food. It also serves a useful purpose 
when substances are taken into the mouth, or even swallowed, 
too hot. A mouthful of cold water will at once lower the 
temperature and obviate any danger of burning. 

After eating we should rest a little while before returning to 
our work. 

Tachyphagia, or hasty eating, is a common evil. The food 



DIET. 139 

is only half masticated, or not at all, and enters the stomach 
without being properly insalivated and comminuted. It is 
easily seen that thus the foundation for many a stomach or 
bowel ailment is laid. 

Brady phagia, or eating too slowly, is, likewise, harmful. 
For very often by such a procedure too little food is taken and 
a condition of insufficient nutrition established. 

Dietetics in Diseases of the Stomach. 

Within the past twenty years important facts have been 
discovered which are of the greatest value in the treatment of 
diseases of the stomach, and the influence of which can be per- 
ceived like a red thread through the whole chapter of dietetics. 
It has been shown by von Xoorden 1 and others that emaciation 
in chronic diseases of the stomach is caused in the largest 
majority of cases — if not, perhaps, in all — not by specific 
poisons circulating in the organism, but by a smaller amount of 
food being taken. On the other hand, one might expect, judg- 
ing from the universal law existing in the plant and animal 
kingdom of vicariousness or replacement in case of inability of 
the work of one organ by another similar one, that in grave 
disturbances of the digestive functions of the stomach the 
intestines would do the work instead. This has been experi- 
mentally, as well as clinically, proven in the most infallible way. 
Several authors (Leube, Ewald, von Xoorden) have observed 
that, in cases of atrophy of the mucous membrane of the 
stomach in which the gastric secretion has entirely ceased, the 
patients can maintain their usual weight. In my paper on 
"Achylia Gastrica'' 1 it is clearly shown that the patients can 
do very well without gastric secretion; under a proper regimen 
they can even gain in weight, and live long without any dis- 
comfort whatever. That means that even after the loss of the 

1 Von Xoorden: Berliner Klinik, Heft 55. 

2 Max Einhorn: Medical Record, 1892. 



140 DISEASES OF THE STOMACH. 

entire chemical action of the stomach, the gut is completely 
able to replace the function of the stomach. 

These two facts — (1) that the emaciation in chronic diseases 
of the stomach is caused by too small a quantity of food; (2) 
that even in grave lesions of the gastric functions the gut appears 
to perform vicariously the digestive work in a complete way — 
are of vital importance for the doctrine of dietetics. For it is 
seen at a glance that the main object of nutrition of the sick 
consists in giving them sufficient quantities of food. 

As people with disturbances of the stomach have to replace 
for their existence no smaller losses than under physiological 
conditions, they will therefore need: 1. Just as large amounts. 
2. The same kinds of food-stuffs as described for the normal 
state. The only difference possible will have reference to the 
selection of the various articles of food and to their form and 
special preparation. 

Thus the question arises, What qualities should the food of 
the stomach patients possess? 

In the treatment of a diseased organ one can often make use 
of two methods. One consists in sparing the diseased organ 
and giving it perfect rest, the other consists in strengthening 
the same by methodical adaptation for more work and practice. 
Both principles are in fact realized in the treatment of diseases 
of the stomach. The first method is ordinarily applied in acute 
diseases and but very seldom (and then only for a short time) 
in chronic affections of the stomach. In these latter the second 
principle, as a rule, is used. The stomach can be spared, firstly 
by not introducing into it any food whatever (greatest degree 
of saving or rest). Secondly, by administering food substances 
which, during their stay in the stomach, do not impose much 
work upon this organ, and do not greatly irritate it. Here the 
main object will be to give the patient easily digestible food. 
In turning from the saving principle to that of strengthening 
the organ by methodical adaptation for work, it will be quite 



DIET. 141 

natural to change the diet, not suddenly, but gradually, into 
such as requires more work on the part of the stomach for its 
digestion. It is therefore absolutely necessary to have an exact 
table of digestibility of different foods. In prescribing or 
changing a diet we shall have to act according to it. Such a 
scale has been arranged by different authors. The main sign 
of digestibility was gauged as mentioned above by the rapidity 
with which the various food-stuffs passed out of the stomach 
into the intestines. Beaumont, in many trials on his patient 
with the gastric fistula, determined the length of time the 
different victuals remained in the stomach and constructed a 
scale according to the figures obtained. 

On the same principle, but more reliable and of greater value, 
is the scale constructed by Leube, according to the results 
obtained by emptying the stomach of patients by means of a 
tube, after different kinds of food had been taken. We think 
it advisable and useful here to give Leube's scale: 

First Diet. — Bouillon, Leube-Rosenthal's meat solution, milk, 
raw eggs, zwieback, English cakes (biscuits containing no 
sugar), water, natural acidulous waters (Apollinaris, Kron- 
thaler. Seltzer, etc.). 

md Diet. — Boiled calf's brain, boiled calf's sweatbread, 
boiled chicken (young without the skin), boiled pigeon, boiled 
calves' feet, tapioca pap boiled in milk, beaten white of egg. 

Third Diet. — Raw beef (chopped very fine), raw ham (chopped 
very fine), beefsteak (superficially fried in freshest butter), 
finely scraped tenderloin of beef, mashed potatoes, white bread 
le), coffee with milk, tea with milk. 

Fourth. Diet. — Fried chicken, fried squab, roast venison, guinea 
hen. roast beef (cold), roast veal (leg, saddle), boiled pike, 
macaroni, rice pap, finely chopped spinach, asparagus, stewed 
appl 

This table has been verified by the above-mentioned Pen- 
soldt's investigations. All these experiments, however, only 



142 DISEASES OF THE STOMACH. 

show what food remains in the stomach the shortest time. 
This would perhaps give reason for inferring what food may be 
easily digested as far as the stomach is concerned, but not what 
is more easily digested as a whole, i.e., made use of for the 
economy of the body with the smallest amount of work. The 
digestibility of food substances depends firstly upon their shape 
and quality; secondly, upon their percentage of convertible 
material. 

" Corpora non agunt nisi fluida," is an old, well-known axiom. 
Following this law one could arrange the following scale of 
digestibility, which is constructed according to the different 
physical conditions of the food: 

1. Food in liquid form: (a) Liquid at ordinary temperature — 
milk, meat juice, beef tea, bouillon, peptone or sarcopeptone 
dissolved in water, bread water, 1 strained barley, oatmeal, rice 
water, strained oyster soup, egg- albumin water; (b) liquid at 
the body temperature — Jellies, fruit jelly, calf s-foot jelly, ice- 
cream, water-ice. 

2. Pulpy form: The food is mechanically converted into 
very minute particles and well mixed in liquid — pap soups 
(barley, oatmeal, farina, rice, sago); egg in bouillon; Leube's 
meat solution, pulverized meat, pulverized crackers in milk, 
water, or bouillon; buttermilk, kumyss, cream, butter. 

3. Food which by slight trituration in fluids separates into 
minute particles: White bread in milk or water; the tips of 
well-boiled asparagus; carrots, mashed potatoes, baked potatoes; 
the yolk of hard-boiled eggs; oysters (raw). 

4. Solid food: White bread, rye bread; meat, hard-boiled 
eggs, fish, cheese. 

5. Substances not easily digested: Meat with tough fibre; 
lobster; sausages and Swiss cheese on account of their solidity; 
all substances containing much cellulose, principally when eaten 

1 Bread water. Stale bread is cut into slices and put in water at tem- 
perature of room for from two to three hours, then the water is strained. 



DIET. 143 

raw: cold slaw; all salads, cucumbers, pickles, raw fruit, apples, 
pears, pineapple; fruit which contains much acid, therefore all 
unripe fruit, strawberries; substances containing much sulphur 
and forming gases in the intestines : all kinds of cabbage, princi- 
pally white cabbage; beans. 

This theoretically constructed scale of the digestibility of 
food is, at the same time, in the main points, similar to the one 
which has long stood the test of empiricism and which I ordi- 
narily employ in my practice. 

Dietetics in Acute Diseases of the Stomach. 

Acute Gastric Catarrh. — The principle of rest here occupies 
the first place. In acute gastric catarrh, dining the first two- 
or three days, in which, as a rule, there is a total loss of appetite, 
only very little nourishment in liquid form should be given, 
containing principally amylacea, barley or oatmeal soup, bouil- 
lon, weak tea, water. As a rule, one must not force a patient 
to take food during the first or even during the second day of 
sickness. The anorexia in these conditions is a wise arrange- 
ment made by nature in order to give the stomach rest. If 
there is thirst, beverages may be taken in small quantities, and 
must be neither cold nor very warm. As soon as the appetite 
reappears one may give some toasted bread or zwieback, milk, 
soft-boiled eggs or oysters, permitting after a while small 
quantities of bread and meat, and then passing slowly to the 
ordinary diet. 

Ulcer of tlie Stomach. — During the rest cure of von Ziemsscn- 
Leube give liquid diet, consisting principally of milk, for two 
or three weeks. As is well known, Cruveilhier 1 first recom- 
mended milk for the purpose, and even now there are some 
physicians who limit themselves to milk alone. As a rule, 
however, it is appropriate to allow, besides milk, milk in com- 

1 "Anatomie Pathol.," 1829-35. 



144 DISEASES OF THE STOMACH. 

bination with barley, oatmeal, or rice water. In addition to 
this, the different peptone preparations are here in place. I ad- 
minister Rudisch's sarcopeptone, manufactured in this country, 
on account of its being palatable and highly nourishing. Valen- 
tine's and Wyeth's beef juice, tropon, plasmon, somatose, 
sanatogen and the like may all be used for the same purpose. 

One may give most appropriately every two hours one to 
two cupfuls of milk with the addition of the above-named 
decoctions (four times daily) and sarcopeptone (twice daily.) 
The patient must not drink these fluids, but eat them with a 
spoon. In case of hemorrhage of the stomach during the first 
three or four days, it is not permitted to give any food whatever 
by the mouth; instead, the patient must be fed by the rectum. 
Ewald has proven that the large intestine has the ability of 
digesting and absorbing albuminates even without special 
previous preparation; therefore the following may be given as 
a nutritive enema: 

1. Three to five eggs are mixed with 150 c.c. of sugar water 
(30 gm. of grape sugar dissolved in 150 c.c. of water), a small 
quantity of common table salt is added, and the whole mix- 
ture well beaten; one may add also a small quantity of starch 
solution or mucilage. 

2. One-half pint of milk with two eggs and 50 gm. of grape 
sugar added. 

3. One and a half tablespoonfuls of somatose or peptone 
dissolved in a cupful of water. 

The food enemata have to be given three or four times daily. 
It is necessary that the fluid should be at the temperature of 
the blood, and that it should be injected by means of a fountain 
syringe and a soft-rubber rectal tube. Each morning before 
giving the first nourishing enema a cleansing enema of 1,000 c.c. 
of lukewarm water has to be administered, in order thoroughly 
to cleanse the large intestine and make it more fit for absorption. 
In order to facilitate the retention of the feeding enema W. 



DIET. 145 

Oilman Thompson 1 suggests the following procedure: Upon 
withdrawing the tube, if there is danger that the injection will 
not be retained, a soft compress or folded towel should be 
pressed up firmly against the anus for twenty minutes or half 
an hour. In case of thirst the patient is allowed to take small 
pieces of ice into the mouth from time to time. Thirst and 
hunger, however, may be entirely relieved by nutrient enemata 
alone. "In an obstinate case of gastric hemorrhage in which 
absolutely nothing, not even water, was given by the mouth 
for more than a week," W. Oilman Thompson 2 says, "I ques- 
tioned the patient in regard to her sensations of hunger and 
thirst, and she told me that they mere entirely relieved after the 
first twenty-four horns' use of nutrient enemata. The mouth 
and tongue were not dry and she did not lose weight during this 
period." Three days after the disappearance of blood one 
slowly and cautiously begins the liquid diet. 

Dietetics in Chronic Affections of the Stomach. 

While in acute diseases of the stomach we pay most attention to 
giving rest to the organ — for here even an insufficient nutrition 
and the loss of several pounds of bodily weight are not of much 
importance, as the quickly recuperating organism replaces the 
- caused during the sickness by taking increased quantities 
of food — in the chronic affections it is of utmost and vital 
importance to see that sufficient quantities of food are taken. 

The greatest number of stomach patients consulting the 
physician, after the disease has been progressing quite a while, 
have lost more or less weight. The principal reason for this 
lies in the fact that the body has received too small a quantity 
of nourishment in order to replace the waste. 

The ordinarily insufficient appetite, the early appearance 

1 W. Oilman Thompson: "Practical Dietetics, with Special Reference 
to Diet in Disease/' New York, 1895. 

2 W. Gilman Thompson: /. c. 

10 



146 DISEASES OF THE STOMACH. 

of a feeling of satiation, the pain often appearing after meals, 
and less frequently vomiting, are the principal factors of sub- 
nutrition. 

At this point it becomes necessary to divide the patients with 
stomach troubles into two large classes: 

1. Into those with organic lesions of the stomach. 2. Into 
those with functional disturbances. 

The first class comprises, (a) the malignant diseases of the 
stomach itself or its orifices (carcinoma ventriculi, cardise, 
pylori); (b) cicatrical strictures of the cardia or pylorus; (c) 
absence of secretory work of the stomach; achylia gastrica. 

In this whole first class, with the only exception of group c, 
which lies, so to speak, between the first and second class, we 
are unable to accomplish much either by medicinal treatment 
or dietetics. In existing strictures of the cardia or pylorus 
it will be necessary to seek surgical aid. Even in cancer of the 
stomach wall the resection of the affected part is advisable 
whenever the operation is possible. I cannot refrain from 
calling attention at this place to the splendid results of the 
recent stomach surgery, which of late has been frequently 
practised in our own country (F. Lange, N. Senn, R. Abbe, 
Willy Meyer, McBurney, Weir, Bull, Gerster, Roswell Park, 
Murphy, Mayo, and others). In carcinomatous strictures a 
new passage can be established, either for bringing food into 
the stomach by a gastric fistula, or for allowing it to pass into 
the intestine, by gastro-enterostomy. In this way we succeed 
at least in temporarily giving these unfortunates relief and in 
ameliorating their nutritive condition. In the cicatricial 
strictures we are warranted in promising to the patients, now- 
adays, perfect recovery by undergoing operative treatment. 
(In strictures of the cardia a methodical dilatation with bougies 
may sometimes also suffice.) The pyloroplasty operation (of 
Heincke-Mikulicz) and the cardiotomy or cardio-fissure (Abbe) 
belong to the most beautiful and blissful operations which have 



DIET. 147 

ever been practised. After the operation the patients are 
enabled to eat everything, and to live without any trouble 
whatever, i.e., they are perfectly cured. 

Before the operations, or if such are unfeasible, one should 
administer light, very slightly irritating nourishment, and 
always endeavor to make the patient partake of a larger quan- 
tity of food. If there is obstinate and constant vomiting, 
it is necessary to employ nutritive enemata. 

up (c) achylia gastrica will be advantageously discussed 
in regard to diet under Class 2. 

The second class of functional disturbances includes the 
st number of all dyspeptics. Here stand uppermost 
chronic gastric catarrh, atony of the stomach, dilatation of the 
stomach, gastroptosis. superacidity, with or without hyper- 
secretion, nervous gastralgia, nervous dyspepsia, and as an 
intermediary between the first and second class, achylia 
ica. 
It appears advisable to discuss first the whole class, and 
thereafter to give special rules for the different groups. Liquid 
food or partly predigested substances (as all peptone prepara- 
not in place here. By making the stomach work too 
the weakened condition of this organ is retained and 
ted in time. Wo must always bear in mind the princi- 
ple of strengthening the organ by means of appropriate work. 
A well-known clinician is said to express himself in his 
lectures in the following way regarding the dietetics of the 
peptic: 
When a dyspeptic patient asks you the question, "What 
shall I I • .'" reply. "Eat what you like." if he asks, "How 

much .-hall I i v to him. "Eal a- much as your appetite 

ods." If he Mill asks, "When shall 1 eat?" answer 
"Eat when you are hungry." 
Although I do not favor strict and severe dietetic rules, 
I deem the above-ment iouod remarks as goin 



14S 



DISEASES OF THE STOMACH. 



far. Unlike the normal healthy condition, in which instinct 
shows us the right measure to eat, neither too little nor too 
much, stomach patients often have lost the feeling of self- 
regulation, and as a rule partake of too small quantities of food. 
(Only in a few cases of bulimia there may be an increased 
desire for food, and in connection with it the quantity of food 
taken may sometimes be too large.) It is therefore necessary 
to instruct the patients to eat more, or to give them exact 
figures of the quantity of food required. As this varies with 
every individual it is most practicable to let the patient weigh 
himself once a week and to see whether he keeps his weight. 
If the patient does not lose any it is the best sign that he takes 
sufficient nourishment. As good instances of a sufficient 
amount of food contained in the diet we give the following bills 
of fare which have been suggested by C. von Noorden: 1 



I. A Principally Milk Diet with Addition of Carbohydrates in 

Liquid Form. 





Albumin, 
per cent. 


Fat, 
per cent. 


Carbo- 
hydrates, 
per cent. 


Calories, 
per 100. 


Milk, 1,700 c.c 


70.2 
10 

7.0 


66.3 


69.7 
30 

40 


1295 


Soup of tapioca flour, 30 gm. and 

10 gm. albumose. 2 
Soup of 40 gm. wheat flour, with 

some of the milk, 10 gm. sugar 

and one egg. 


164 


5.5 


244 


Total 


87.2 


71.8 


139.7 


1703 



1 C. von Xoorden: Berl. Klinik, 1838, J. 55. 

2 10 gm. albumose is contained in 99 cc. of Denayer's peptone prepara- 
tion or in 22 of Kemmerich's or in 30 of Koch's. 



DIET. 



149 



II. Principally Milk Diet with the Addition of Carbohydrates and 
Fat in Pap Form and Soups. 



Albumin, Fat, ' I Calories, 

hydrates, _,. 

per cent, per cent. per 100. 

per cent. 



Milk. 1.500 c.c 

Soup of 15 gm. sago, 10 gm. 

butter, one egg, 10 gm. al- 

bumose. 
Pap of SO gm. corn flour, one egg, 

10 gm. sugar (two meals). 

Total 



62 
17 



58.5 
13.5 



5.5 



63 
15 



90 



1056 
257 



398 



168 1711 



III. Milk Diet with Addition of Light Pastry and Broths. 



Albumin, Fat, 
per cent, per cent. 



Carbo- 
hydrates, 
per cent. 



Calories, 
per 100. 



Milk. 1.250 c.c 

Meat broth with one egg, 10 gm. 

of butter, 50 gm. of fine toasted 

wheat bread. 

Cakes 70 gm., butter 15 gm 

Soup of 30 gm. tapioca flour, one 

egg, 10 gm. butter. 

Total 



51 


49 


52 


878 


10 


14 


30 


294 


5 


12 


50 


337 


7 


14 


30 


282 


73 


89 


162 


1791 



150 



DISEASES OF THE STOMACH. 



IV. Milk with Tender Meat, Pastry, Butter, and Soups. 



Albumin, 
per cent. 



Fat, 
per cent. 



Carbo- 
hydrates, 
per cent. 



Calories, 
per 100. 



Spring chicken, 100 gm 

Mashed potatoes, 100 gm. . . . 

Two eggs 

Toasted wheat bread, 100 gm 

Butter, 30 gm 

Trout, 100 gm 

Milk, 1250 c.c ;. .. 



19.6 

2.0 

14.1 

7 



19.3 
51 



Total 



113.0 



2.8 

4.0 
11.0 

0.5 
23.0 

2.1 
49 



92.4 



20 
55 



52 



127 



106.4 
127.4 
160.1 
258.8 
213.9 
106.4 



1851 



V. Rich, not Irritating Diet. 



Albumin, 
per cent. 



Fat, 
per cent. 



Carbo- 
hydrates, 
per cent. 



Calories, 
per 100. 



Tender meat, 1 250 gm. 

Cacao, 20 gm 

Three eggs 

100 gm. Zwieback 

100 Wheat bread 

50 gm. cakes 

50 gm. butter 

40 gm. tapioca flour . 

40 gm. corn flour. . . . 

20 gm. sugar 

1250 c.c. milk 



Total. 



49 

4 

21 

8 
7 
4 



7.0 
6.0 

16.0 
1.0 
0.5 
2.3 

44.0 



51 



49 



144 



125. 



75 

55 
36 



40 
40 
20 
52 



326 



266 
105 
235 
259 



187 
407 
164 
164 

82 
878 



2747 



1 Meat of various kinds, finely chopped, raw or fried in butter; cold or 
warm, taken at two meals. 



DIET. 151 

Besides the importance of a sufficient diet, we must remind 
patients to lead a regular life, to eat slowly (how many, especi- 
ally in our country, sin against this natural law!), and to chew 
well and triturate the food. One must avoid either extremely 
cold or extremely warm food. Too copious and too compli- 
cated meals must be strongly forbidden. 

I have made it a rule not to forbid anything, except what is, 
according to my conviction, obnoxious in the given case. In 
this way the patients have a great variety in their food and run 
less risk of subnutrition. Likewise we need not change the 
number of meals nor the horns appointed unless there should 
be especial indications for such a proceeding. 

Among the laity, as well as often among medical men, there 
are prejudices against certain forms of food. Thus, for instance, 
until recently it was customary to forbid all kinds of fat, even 
butter, in all dyspeptic conditions. Fat, however, belongs to 
the group of food-stuffs which has the largest number of heat 
units, and besides, is not bulky as a nourishment (butter). 
Undecomposed fat passes the stomach without molesting the 
latter, and is digested in the small intestine. There is, there- 
fore, no reason for forbidding butter, which should, on the 
contrary, be highly recommended. Fearing fermentative 
processes the partaking of bread and other food rich in carbo- 
hydrates is very often greatly limited, or even totally forbidden. 
Although it is true that the carbohydrates easily undergo fer- 
mentative processes, those cases, however, in which considerable 
fermentations exist in the stomach are quite rare, and as a rule 
are found only where there is considerable stagnation of food in 
the stomach. In these cases, to be certain, a diet consisting 
principally of animal albumin (meat) for a short period is very 
useful. By means of lavage of the stomach and other appropri- 
ate treatment we soon succeed in checking the fermentative 
processes, and carbohydrates can then be administered. 



152 DISEASES OF THE STOMACH. 

An adult, according to Koenig, 1 daily consumes J to £ 
kgm. of bread; fifty to sixty per cent, of the total food sub- 
stances, and fifty to seventy-five per cent, of the carbohydrates. 
arc taken in the form of bread. This clearly shows the important 
part bread takes in diet. Its use is, therefore, as a rule advis- 
able. It is ordinarily said that crust of bread, stale bread, and 
zwieback are easier to digest, on account of the starch contained 
in them being largely converted into dextrose. Although I am. 
of the opinion that too fresh bread must be avoided, I never- 
theless rarely find much difference in the digestibility of the 
crust or other parts of well-baked fine white bread, judging 
from experience gained from my own patients. 

Moreover, the carbohydrates in the form of sugar (taken in 
large quantities) have been found by the painstaking investiga- 
tions of Dr. W. Gerry Morgan, 2 of Washington, D. C, to lessen, 
the amount of acidity in the stomach. Sugar can, therefore, 
be administered with advantage in cases of hyperchlorhydria. 

Articles of luxury (wine, beer, coffee, tea) are, as a rule, per- 
missible. It is, however, necessary to give them in small 
amounts and in appropriate form. Strong liquors must be 
avoided, likewise all strong spices. 

Appetizers, as a small amount of caviare, sardellen, or 
anchovies, on a small slice of bread or cracker, taken one- 
quarter of an hour before the meal, are not only allowed but 
frequently directly commendable. 

In reference to the special rules for the different diseases of the 
second class, we shall have at times to reduce the quantity of 
meat taken in all conditions accompanied by a diminished 
secretion of hydrochloric acid (gastritis chronica glandularis, 
atony + subacidity) ; on the other hand, the quantity of richly 



1 Koenig: "Die menschlichen Nahrungs- und Genussmittel/' Berlin. 
1883, p. 430. 

2 Dr. W. Gerry Morgan : " Zucker, als solcher, in der Diat der Dyspep- 
tiker." Arch. f. Verdauungskrankh., 1902, p. 152. 



DIET. 153 

carbohydrate vegetable food must be increased. Kumyss, 
zoolak, milk with cognac (7 to 10 c.c. of cognac to 200 or 250 
c.c. of milk) may be taken with crackers either dming or 
between meals. 

In all the conditions attended with super acidity the quantity 
of albuminous food should be increased; here one may give a 
great deal of meat (venison included). In superacidity with 
hypersecretion frequent and small meals containing consistent 
food are most appropriate. If there is a feeling of hunger 
between meals, the white part of hard-boiled eggs may be taken 
(as is well known, albumin combines with acid and makes it, 
so to say, inert). The quantity of beverages must be greatly 
limited; most suitable in this instance are small quantities of 
Vichy water. In dilatation of the stomach and in gastroptosis 
it is also advisable to give small and frequent meals, and to 
restrict the quantity of liquids taken. As a rule, milk and 
beer do not agree well in these cases. Small quantities of wine 
or imported dark beer or porter may be allowed. 

In nervous dyspepsia and gastralgia our main object will be 
to systematically increase the quantity of food — here milk and 
its derivatives (koumyss, zoolak, bonny-clabber, buttermilk, 
cream) taken between meals play a great part (Weir Mitchell 
treatment) . 

In achylia gastrica it is of utmost importance to give liquid 
or very well triturated (pulverized) food. For here the chem- 
ical action of the stomach has entirely ceased, and vegetable 
(on account of the albuminous membrane enclosing the starch 
granules) as well as animal food pass from the stomach un- 
changed, and not converted into small particles, into the intestines 
and irritate them, unless there has long been formed a sufficient 
adaptation for these conditions. Vegetable food, on account 
of its containing chiefly carbohydrates, will be predominant in 
the diet of this affection. Thus achylia gastrica, in reference 
to diet, stands midway between the first and second classes. 



154 DISEASES OF THE STOMACH. 

It approximates the first class in so far that it necessitates a 
liquid or mechanically minutely triturated or pulverized food, 
the second class in allowing a richly carbohydrate diet. 

Some readers may miss exact bills of fare for chronic affec- 
tions of the stomach. They have been omitted, as it is always 
necessary to individualize, especially in diet. We must guide 
ourselves more by the patients than by theoretical conclusions. 
Our main object must be to care for a sufficient nutrition. 
Only the above-given principal rules on diet must be observed, 
although at times even they have to be modified. In reference 
to this point Hippocrates 1 said: "Dandum aliquid tempori, 
regioni, cetati et consnetudini" 

At present, with our more exact knowledge, we have come to 
appreciate this conclusion to a still greater degree. 

1 Cited from Munk and Uffelmann, loc. cit., p. 430. 



CHAPTER IV. 

LOCAL TREATMENT OF THE STOMACH. 
1. Lavage. 

Gastric lavage, which is so frequently employed in the 
treatment of diseases of the stomach at the present day, was 
first introduced by Kussmaui 1 in 1867, who used for this pur- 
pose the stomach pump. Previous to that time this method 
had been practised by Bush, Arnott, Sommerville, and Blutin, 2 
but to Kussmaui belongs the credit of employing it in a rational 
and scientific manner. The illustration (Fig. 56) affords an idea 
of the mechanism of the instrument employed by the latter 
observer winch, however, is now only of historical interest, 
since it has been supplanted by simpler apparatuses based upon 
the principle of siphonage. 

(a) Funnel Arrangement. — The one that is most commonly 
in use consists of a glass funnel attached to a piece of soft- 
rubber tubing of about one yard in length which can be slipped 
over the upper end (connecting glass tube) of the stomach tube. 
By filling the funnel with water, and alternately raising and 
lowering the same, the stomach may be filled or emptied. The 
funnel, as a rule, is not very large and has a capacity of about 
300 to 500 c.c. Ewald 3 advises the use of a very large funnel of 
about two quarts capacity. This rests in a wooden frame on 
the floor and after being filled with the requisite amount of 
water is then raised to a height suitable to obtain the amount of 

'Kussmaui: "Ueber die Behandlung der Magenerweiterung durch eine 
neue Methode mittelst der Magenpumpe." Deutsches Archiv f. klin. 
Med., vol. vi., p. 455. 

- See Ewald: "The Diseases of the Stomach," New York, 1892, p. 5. 

3 C. A. Ewald, I. c, p. 64. 

155 



156 



DISEASES OF THE STOMACH. 



pressure desired. The water escapes from the various openings 
in the tube as from a sprinkler, and the stomach is in this way 
irrigated. To siphon the water out of the stomach, the funnel 
is again placed in the wooden frame, and thus the fluids of the 
stomach return. Here the whole quantity of the wash-water 
can be easily inspected. 

(b) Leube-Rosenthal Apparatus. — The raising of the big 
funnel is quite troublesome, and I therefore prefer to use in my 
own practice the Leube-Rosenthal apparatus winch I consider 
the best means of washing out the stomach (see Fig. 57). This 
consists of a large glass irrigator of about two to three quarts 




Fig. 56. — Kussmaul's Stomach Pump. 

capacity. Leading from the irrigator a large piece of soft- 
rubber tube is connected by means of a Y-shaped glass tube 
first with the stomach tube, secondly, with another quite long 
piece of soft-rubber tubing. Both arms of tubing, the one 
running from the irrigator the other into a waste vessel, are 
provided with clamps. By opening the clamp on the irrigator 
tubing, the water runs into the stomach. By closing the same 
and opening the tube running to the waste vessel, the water is 
withdrawn from the stomach. The amount of water which is 
used for each single filling of the stomach may vary from 400 c.c. 
to a litre. The stomach may be filled with water so long as the= 
patient does not experience any pressure. As soon as he begins* 



LOCAL TREATMENT OF THE STOMACH. 



157 



to feel some pressure, the quantity should not be increased, but 
at once withdrawn. This manoeuvre can be repeated twice or 
three times at each sitting. In case larger quantities of mucus 
are present in the wash water, it is best to have the patient 
shake himself, especially his abdomen, while the water is enter- 




Fig. 57. — Leube- Rosen thai Apparatus for Gastric Lavage. 



ing the stomach. In this way it is possible to mechanically 
clean the organ much more thoroughly than would otherwise 
be the case. The same method of shaking has to be applied if 
the stomach contains some food. 



158 



DISEASES OF THE STOMACH. 



The advantages of this apparatus are quite manifold: 

1. The ease with which the whole procedure can be executed. 

2. The water introduced into the stomach is always clear, 
as the waste water passes through a separate tube; while in the 
use of the funnel arrangement after the first filling the funnel 
and the tubing become soiled during the withdrawal of the 
contents, and in consequence of this, during the second filling, 

much of the mucous which has re- 
mained within the apparatus re- 
turns to the stomach. 

(c) Friedlieb's Apparatus. — An- 
other very suitable arrangement 
for washing out the stomach, especi- 
ally if the patient has to perform 
the procedure himself, is an appa- 
ratus that has been in use in this 
country for many years, and is 
similar to the one described by 
Friedlieb. 1 It consists of a long 
piece of soft-rubber tubing of about 
two yards in length, the middle of which is expanded into a 
bulb. The stomach end of the tube is provided with two big 
openings, while the other is shaped into a funnel (see Fig. 58). 
In the withdrawal of the gastric contents with this apparatus 
the tube should be closed with two fingers at a point situated 
between the bulb and the lips of the patient. If the bulb is 
now compressed, and the two fingers applied to its distal side, 
then on relaxing the pressure on the bulb it will become filled 
with stomach contents. By again closing the upper end of the 
tube and compressing the bulb, the contents will flow out from 
the apparatus. In this way the contents of the stomach can be 
removed. The washing of the organ is now executed in the 
usual way by filling the funnel end with water, raising the same 

1 Friedlieb: Deutsche med. Wochenschrift, 1893, No. 51. 




Fig. 58. — Friedlieb's Apparatus 
for Gastric Lavage. 



LOCAL TREATMENT OF THE STOMACH. 159 

and lowering again. The bulb then need not be compressed if 
the water flows out easily. If the stream of water stops flowing 
before the entire quantity has left the stomach, then suction 
by means of the bulb must be performed as above described. 
Instead of using the fingers in order to compress the tube, two 
clamps on both sides of the bulb may serve the same purpose. 
(d) Several writers have tried to wash out the stomach by 
means of a tube a double coward. Very recently J. C. Hem- 
meter 1 in the country anew devised such an apparatus for this 
purpose. According to my opinion, however, all these devices 
are unnecessary. Lavage of the organ cannot be accomplished 
more thoroughly by means of these than by the three above- 
described simple apparatuses. 

A Few Rules Concerning the Application of Lavage. 

The introduction of the tube has to be performed as above 
stated, when we spoke of the introduction of the tube for the 
withdrawal of gastric contents for examination. During the 
introduction of the tube, it is necessary to have the patient 
hold his head slightly bent forward (as a rule, patients try to 
throw their heads far back, which is a great obstacle to the 
entrance of the tube into the oesophagus). The insertion of 
the tube has to be done quite rapidly. During the entire pro- 
cedure it is best to have the patient breathe deeply. It is 
furthermore of importance to hold the tube with the hand not 
far from the mouth of the patient in order that the apparatus 
may not move up and down and in this way cause irritation of 
the stomach and produce nausea and spells of vomiting. In 
• the outflow of the fluid is suddenly arrested (by food par- 
tide- obstructing the opening of the tube), a small quantity of 
water has to be poured in again, and the siphoning repeated. 
How long and how often the stomach should be washed out is 

1 J. C. Hemmeter: New York Medical Journal, March 30th, 1895. 



160 DISEASES OF THE STOMACH. 

difficult to define. As a rule, this procedure should be kept up 
until the water returns quite clear. The appearance of blood 
in the wash water necessitates the withdrawal of the tubing. 
If, however, only a few blood stains are visible in the water, they 
are of no import, and the lavage can be continued. 

Indications. 

Aside from diagnostic purposes lavage must be performed 
(1) when there is stagnation of food in the stomach; (2) when- 
ever large quantities of mucus are present in the organ. 

Contra-inclications . 

These comprise all conditions in which introduction of the 
tube is not permissible, as for instance, hemorrhages, ulcer of the 
stomach, etc. 

2. The Gastric Douche (Malbranc). 1 

By the gastric douche is meant a sprinkling of the stomach 
with water under high pressure. This can be done by raising 
the funnel of the washing apparatus to a considerable height. 
Ewald's tube, which has several small openings and one large 
one, is most suitable for this purpose. Rosenheim 2 likewise 
makes use of a similar tube. Boas employs a tube with many 
small openings of pinhead size. The latter, however, has the 
disadvantage that the water cannot return quickly. The 
gastric douche was applied by Malbranc and afterward by the 
above-named writers in order to combat severe gastralgias. 

According to my experience there is but little difference 
between lavage and douching of the stomach. In fact, every 
form of lavage has almost the same effect as the gastric douche. 

1 Malbranc: Berl. klin. Wochenschr., 1878, No. 4. 

2 Th. Rosenheim: " Ueber die Magendouche." Therapeutische Monat- 
shefte, 1892. 



LOCAL TREATMENT OF THE STOMACH. 161 

Of late M. Gross, 1 of New York, has devised a double-current 
gastric douche. 

The double-current tube has the disadvantage that its size 
is quite considerable, and its introduction into the stomach of 
the patient is not very convenient. 

In order to have an apparatus which could be introduced 
without any inconvenience, and which would at the same time 
allow a thorough douching of the stomach, I 2 have constructed 
a new gastric douche. Its principle is based upon a valve 
arrangement. The apparatus consists of a rubber tube, not too 
flexible (thickness three-eighths of an inch, length twenty-six 
inches), at the end of which a hard-rubber capsule is attached 
(Fig. 59). The latter contains numerous very small openings 
all around, and one very large opening at its lower extremity. 
Within the capsule, which can be screwed apart, lies a small 
aluminum ball. This moves easily and freely within the cap- 
sule, and when it lies above the lower opening it entirely 
occludes the same. Two cross bars in the capsule prevent the 
entrance of the small ball into the tube (Fig. 60). If the tube 
described is attached to an irrigator provided with a waste pipe, 
the apparatus is complete. If the waste pipe is closed, and the 
water made to run through the douche, the liquid will press the 
ball downward, thus closing up the large opening. The water 
will then come out through the small side openings like a very 
fine shower, sprinkling over quite a large area (Fig. 61). The 
inflowing tube being closed, and the waste pipe opened while 
the capsule is inserted into the liquid, the latter will push the 
ball upward, and thus the large opening will be free, and the 
water will easily return through it. The liquid will cer- 
tainly return not only through the large opening, but also 
through the numerous small side openings. While these, how- 

1 M. Gross: Medical Record, 1895. 

2 .Max Einhorn: "A Now Gastric Douche." Medical Record, Decem- 
ber 2d, 1899. 

11 



102 



DISEASES OF THE STOMACH. 



however, do not admit the return of coarse particles, the 
latter will easily be able to pass through the large hole. 

Method of Using. — The douche end of the apparatus is dipped 
into warm water and then inserted into the stomach. It is 
necessary to pay attention that the capsule lies immediately 
below the cardia and is not situated deeply in the stomach. 



Fig. 61 




Figs. 59, 60, 61. — Einhorn's Gastric Douche. 

The length of tubing from the mouth should be sixteen and one- 
half to seventeen inches. It may be useful to make a mark at 
this point of the tube. The tube is now attached to the irri- 
gator, the outflowing pipe closed, the inflowing one opened, 
and the stomach sprinkled with about a quart of water. In 
order to make the water return from the stomach, the tube is 



LOCAL TREATMENT OF THE STOMACH. 163 

inserted a little farther into the stomach, about four to six 
inches, the outflowing pipe opened, and the inflowing one closed. 
The liquid from within the stomach now returns. This pro- 
cedure may be repeated three to four times. The temperature 
of the water should be regulated according to the therapeutic 
indications. The douche may also be connected with two 
irrigators, one containing cold, the other w r arm water; the 
stomach may thus be sprinkled alternately with cold and w T arm 
water. 

Both lavage and the gastric douche have been made use of 
for the application of medicaments directly to the mucous 
membrane of the stomach. Thus, for instance, various an- 
tiseptic solutions have been applied (boracic acid, salicylic 
acid, sodium salicylate, thymol, creolin, lysol, etc.). Again, 
chloride of sodium on the one hand and nitrate of silver on 
the other (the one to increase, the other to diminish gastric 
secretion) have been used by Boas and Rosenheim. 1 

The solution introduced into the stomach by means of the 
apparatus is left there for a few minutes (two to five) and then 
withdrawn. This procedure has the great disadvantage that 
in order to apply a solution in the right concentration, covering 
the whole inside of the stomach, a considerable quantity of the 
medicament is absolutely necessary. The quantity of the 
agent has to exceed the normal dose, and reach the poisonous 
limit. Although by emptying we certainly remove the greatest 
part of the solution and in this w T ay the danger of intoxication 
is greatly diminished, nevertheless a considerable quantity of 
the injected fluid may pass through the pylorus into the intes- 
tine beyond our control and at times may do harm. That 
La the reason why nitrate of silver and similar poisonous sub- 
ea should not be introduced into the stomach by these 
mean.-. 

1 Rosenheim: L. C. 



104 



DISEASES OF THE STOMACH. 



3. The Gastric Spray (Einhorn). 1 

In cases in which it is necessary to apply medicaments of a 
toxic or irritating character to the gastric mucosa, the risk of 
poisonous effect can be prevented by the use of the spray, by 
means of which large surfaces can be covered with a compara- 
tively small amount of fluid. 

In order to make use of the spray in diseases of the stomach, 
the usual spray apparatus has been modified by me in such a 
way that instead of the hard-rubber branch of the apparatus 




Fig. 62. — The Gastric Spray Apparatus (Einhorn). 

the same branch is made of soft rubber and lengthened. In 
this way the gastric spray apparatus consists of the usual spray 
apparatus, in which there is a soft Nelaton tube, of 70 cm. 
length, inserted between the nozzle and the hard-rubber branch 
running to the bottle; within the Nelaton tubing, another soft 
tube of thinner calibre connects the inner capillary tube with 
the nozzle (see Fig. 62). 2 

As the spray is generated by the air forced by the bulb 
through the tube, taking up the fluid and dividing it into fine 



1 Max Einhorn: "The Use of the Spray in Diseases of the Stomach." 
New York Medical Journal, September 17th, 1892. 

2 The gastric spray apparatus is manufactured by Geo. Tiemann & Co., 
New York. 



LOCAL TREATMENT OF THE STOMACH. 165 

particles, the medicament will necessarily come in contact with 
every part touched by the air. 

If the stomach is empty when spraying, the air that enters 
will expand the organ and transport the fluid to every part of 
its interior. 

The administration of the spray in gastrotherapeusis is a 
suitable form for fulfilling the following purposes: 

1. To disinfect the mucous membrane of the stomach. 

2. To exert an astringent effect. 

3. To produce analgesia in gastralgia of local character 
(from ulcer, cicatrix, or cancer). 

Method. — As it is possible to spray the stomach only in its 
empty state, it will be necessary to administer the spray either 
when fasting or after a previous lavage. 

A preceding lavage will always be indicated if we intend to 
disinfect or apply astringents, for in these instances it is neces- 
sary first to remove the mucus with the micro-organisms 
embedded therein. In order to exert an analgesic influence, 
the lavage may perhaps be omitted. 

After filling the apparatus with a sufficient amount of the 
required solution, the tube end is dipped into warm water and 
thereupon inserted into the stomach of the patient. It is best 
to begin with the spray as soon as the nozzle (being in the 
stomach) is at a distance of about 45 cm. from the lips of the 
patient. Provided the nozzle is not covered by the stomach 
wall, there can be heard during the spraying, at times in the 
neighborhood of the patient — otherwise by putting the ear on 
the gastric region — the sound characteristic of the spray. In 
ease the opening is covered, the spray is generally unable to 
and it is then necessary to insert the tube a little farther. 

Even if the spray works well from the beginning, it will be 
expedient after a while to introduce the tube a little farther, in 
order to have the spray work from different points. The spray- 
ing of the stomach has proved very useful, according to my 



l(i() 



DISEASES OF THE STOMACH. 



experience, in the following conditions: (1) In erosions of the 
stomach; (2) in those forms of chronic gastric catarrh which 
are associated with an abundant amount of mucus; (3) in cases 
of hypersecretion and hyperacidity. 

4. The Stomach Powder Blower (Einhorri). 

By means of the spray only soluble drugs can be applied, 
but not substances which are either soluble with great difficulty 




Fig. 65- 



Fig. 63. — The Stomach Powder Blower. A, The tubing part; B, connection with the 
bulb ; C, hard-rubber end with screw thread for capsule. 

Fig. 64. — (Natural size.) The Capsule-shaped Powder Receptacles. 
Fig. 65. — The Small Spoon for Putting the Powder into the Capsule. 

or not at all. In order to facilitate the introduction of the 
latter I 1 have devised a powder blower for this purpose. The 
stomach powder blower 2 (Fig. 63) consists of an ordinary, not 
too flexible rubber tube (A), twenty-eight inches and a half 
long, the distal end of which connects by means of a hard-rubber 
piece with an air-suction bulb (B), the approximate end of 
which is attached to a hard-rubber piece (C). The latter is 
hollow and pierced with several small openings at the side for 

1 Max Einhorn: "A Powder Blower for the Stomach." New York 
Medical Journal, April 1st, 1899. 

2 The stomach powder blower can be obtained at Geo. Tiemann & Co., 
New York. 



LOCAL TREATMENT OF THE STOMACH. 167 

the passage of air, and provided with a screw-thread for the 
capsule. The capsule (D) has numerous holes, and is made in 
three different sizes (3, 3 1/2, and 4 cm. long) (Fig. 64). It is 
filled with the necessary quantity of powder by means of a very 
small spoon (Fig. 65), and screwed on to C. 

Method. — Insufflation of the stomach with powder can 
naturally be done only when the organ is empty. It should, 
therefore, be performed in the fasting condition, and, in cases 
in which the stomach is not empty in the morning, after previ- 
ous lavage. Proceed as follows: According to the quantity of 
medicament required, one of the capsules, D, E, or F, is filled 
with the powder and screwed on to the apparatus. The tube 
is moistened with warm water and inserted into the stomach. 
The bulb is then compressed three or four times in quick suc- 
cession. By holding the ear over the gastric region of the 
patient dming insufflation the entrance of air (consequently 
also of the powder) is distinctly heard. In cases in which there 
is much mucus in the pharynx and oesophagus its entrance into 
the holes of the capsule may be prevented by covering them 
with vaseline in a thin layer. The latter forms a protecting 
covering and prevents liquids from coming in contact with the 
powder. "When the apparatus is in the stomach and the bulb 
compressed, the air opens up the vaseline layer over the holes, 
and the powder can now escape. 

The following simple experiment shows that the powder does 
not collect merely at one spot, but rather spreads over the 
entire surface of the gastric mucosa: 

Take a rubber bag (seven inches long and six inches wide), 
• the end of the stomach powder blower filled with powder, 
and draw the strings together (Fig. 66). Then compress the 
bulb two or three times and remove the insufflator from the 
bag. If the latter is now opened, the powder is found equally 
distributed upon the entire inner surface of the bag (Fig. 67). 
Una -hows that the air disseminates the powder as fine dust 



16S 



DISEASES OF THE STOMACH. 



over all parts of the inside of the bag. In the stomach the 
conditions are not different from those in the bag, and the 
insufflation of the interior of the gastric cavity with the powder 
will thus be complete. I have recently changed the powder 
blower for the stomach. The capsule now has three large holes 
and one small one near the screw-thread. Besides, there is a 
double bulb with a cock arrangement instead of the single bulb 
I formerly used. This modified pow r der blower (see Fig. 68) 




Fig. 66. — A Rubber Bag with the Strings Tightened and within the End of the Stomach 
Powder Blower. 

Fig. 67. — The Bag Opened; the WTiite Spots Showing the Powder. 

acts perfectly, allowing the entire amount of pow T der wdthin the 
capsule to be expelled. The capacity of the big capsule is over 
fifteen grains — i.e., fifteen grains of powder can be thrown into 
the stomach at once. The indications for powdering the 
stomach are manifold: In ulcus ventriculi, bismuth; in gastral- 
gia, orthoform; and in erosion, protargol or suprarenal capsule 
can be directly insufflated. 

5. Electricity. 

In view 7 of the firm foothold gained by electricity in the thera- 
peusis of gastric and intestinal disorders, it will not appear 
superfluous to give a brief review 7 of the history and physio- 
logical action of this agent with reference to the digestive tract. 

Numerous experiments have been made in the study of the 



LOCAL TREATMENT OF THE STOMACH. 169 

influence of electricity upon the stomach and intestines; all of 
them serve to demonstrate the physiological effects of this agent. 

Ludwig and Weber/ von Ziemssen, 2 and Bocci 3 have stated 
that in animals the faradic, as well as the galvanic, current, 
applied directly to the stomach, causes contractions of this 
organ, and produces secretion of gastric juice. 

Schillbach. 4 upon applying the galvanic current to the bowels 
of a rabbit, observed intense contractions at the site of the 
anode, followed by peristaltic movements. Fubini 5 lately 
demonstrated, after making a Telia's double intestinal fistula, 
that electricity quickens intestinal peristalsis to a high degree, 
viz.. about five or six times. 




Fig. 68. 



The influence of electricity upon the stomach and intestines 
thus being evident, many authors endeavored to make use of 
this means in the therapeutics of these organs. 

For many years past numerous writers have employed 
electricity in affections of the stomach and intestines. The 
method generally used for this purpose consisted in the percu- 
taneous application of the current; usually one electrode was 
held in the neighborhood of the vertebral column at about the 

: Ludwig and Weber: Cited from Kussmaul, Arch. f. Psych, und Nerv. 
1877, Bd. viii., p. 205. 

- Von Ziemssen: Klin. Vortrage, Xo. 12, "Die Electricitat in dcr Medi- 
an." 

Bocci: Lo Sperim^ntale, June, 1881. 

4 Schillbach: Virch. Arch., Bd. 109, p. 284. 

'Fubini: Centralbl. f. d. med, Wissensch., 1882, Xo. 33, p. 579. 



170 DISEASES OF THE STOMACH. 

sixth dorsal vertebra on the left side, the second electrode being 
placed at the epigastrium. 

A. D. Rockwell and M. Beard 1 were among the first to make 
use of electricity on a large scale in the treatment of nervous 
dyspepsias. To the application of electricity to the stomach 
they added general electrization, and had the most brilliant 
results. 

Neftel 2 likewise had much success from the electrical treat- 
ment. 

Fuerstner 3 recommends the galvanic current for the treat- 
ment of atonic dilatations of the stomach. 

Oka and Harada, 4 Leube, 5 Lente, 6 Semmola, 7 Richter 8 and 
Leubuscher, 9 speak highly of the application of the electric 
current in various pathological conditions of the. stomach and 
intestines. 

Besides these clinical facts, there have lately been added 
some more exact notes as regards the physiological effects of 
percutaneous electricity of the stomach in man. Ewald and 
myself 10 have been able to demonstrate an acceleration of the 
motor faculty of the stomach under the influence of percutane- 
ous faradization, by the appearance of the salol test in the urine 
about one-fourth of an hour earlier than otherwise. A. Hoff- 
mann 11 showed that the galvanic current percutaneously 

1 A. D. Rockwell and M. Beard: Philad. Med. Surg. Report,, 1868, No. 
20, and 1871, p. 470. 

2 Xeftel: Centralbl. f. d. med. Wissensch., 1876, No. 21, p. 370. 

3 Fuerstner: Berl. klin. Wochensch., 1876, No. 11. 

4 Oka and Harada: Berl. klin. Wochensch., 1876, No. 44. 
5 Leube: Deutsch. Arch. f. klin. Medicin, 1879, tome 23, p. 98. 
6 Lente: Arch, of Electrol. and Neurol., 1874, i., p. 193. 

7 Semmola: " L'elettricita nel vomito." Gaz. med. Ital. Lombard., 
1878, No. 6. 

8 Richter: Berl. klin. Wochensch., 1882, Nos. 13 and 14. 

9 Leubuscher: Centralbl. f. klin. Med., 1887, No. 25. 

10 Ewald and Einhorn: Verhandlungen des Vereins fur innere Medicin, 
1888, p. 58. 

11 A. Hoffmann: Berl. klin. Wochensch., 1889, Nos. 12 and 13. 



LOCAL TREATMENT OF THE STOMACH. 171 

applied in the gastric region for twenty minutes produces an 
abundant secretion of gastric juice. 

Direct Electrization of the Stomach. 

Although the favorable influence of electricity, even percu- 
taneously applied, is quite evident in numerous affections of the 
stomach and intestines, it, however, remains questionable 
whether any of the produced electricity penetrates to the 
stomach. The main currents undoubtedly go through the skin 
and muscles, and if any of them reach the stomach, they must 
be very weak. But surely we might expect to attain better 
and more successful results by the application of electricity 
directly to the stomach. In his celebrated book on "Electro- 
therapy" Erb 1 says: "The first maxim to observe is the 
treatment in loco morbi, i.e., the application of electricity to 
the morbid part itself. . . . There is no doubt that it is 
best, in the great majority of cases, to operate directly on the 
diseased spot." 

Pepper 2 had a patient with dilatation of the stomach, in 
whom the abdominal walls were so thin that the spontaneous 
peristalsis of the stomach could be perceived. On this patient 
he showed that electricity, percutaneously applied, never pro- 
duced any peristaltic movements of the stomach. Pepper then 
continues as follows: "The difficulty of compelling a current, no 
matter what may be its strength, to penetrate through various 
layers of tissue of different consistence and anatomical character 
La well known." Speaking of the percutaneous electricity of 
the stomach, Kussmaul 3 remarks: "The therapeutic results 
obtained by Fuerstner and others in cases with dilatations of 
the stomach do not prove that by means of the current a direct 
peristalsis of the stomach was induced, but could be attributed 

1 Erb: "Handbuch dor Eloctrotherapio," p. 279. 

►per: Philadelphia Medical Times, May, 1871, p. 274. 
-rnaul: Arch. f. Psych, und Xerv., 1877, viii., p. 205. 



172 DISEASES OF THE STOMACH. 

to the favorable influence of the contractions of the abdominal 
walls." All the sentences mentioned plead for applying elec- 
tricity to the stomach directly, and not percutaneously, if 
possible. 

Canstatt 1 first proposed to combat dilatations of the stomach 
by direct electrization, introducing one electrode into the 
oesophagus and putting the other in the stomach region. 
Duchenne 2 was the first who made use of this method. 

KussmauVs Method. — Very soon afterward, in 1877, Kuss- 
maul 3 began to practise the direct electrization of the stomach. 
The electrode used for the purpose consisted of a stomach tube, 
through which ran a copper wire ending in an olive point and 
fastened to the cut-off end of the tube. In several patients 
with dilatation of the stomach Kussmaul introduced this 
electrode into the stomach, the other (ordinary) electrode being 
held in the hand. In applying electricity in this way contrac- 
tions of the abdominal muscles on the left side appeared, and 
in one patient, with thin abdominal walls, contractions of the 
stomach were visible on applying weaker electric currents. 

Later on Balduino Bocci, 4 in 1881, experimenting on ani- 
mals, was persuaded "that the indirect faradization of the 
stomach through the abdominal walls produces in the stomach, 
even when applied in a very energetic way, phenomena of very 
little importance, and of a dubious curative effect." As the 
direct faradization of the stomach, on the other hand, showed 
all the above-mentioned physiological effects, Bocci recom- 
mended anew the use of the direct electrization of the stomach 
for therapeutic purposes. Bocci used for this end an electrode 
like that of Kussmaul. 

BardeVs Method. — Great progress in the direct electrization 



1 Canstatt: Cited from Kussmaul, I. c. 

2 Duchenne: Cited from Kussmaul, I. c. 

3 Kussmaul : L. c. 

4 Bocci: Lo Sperimentale, June, 1881. 



LOCAL TREATMENT OF THE STOMACH. 173 

of the stomach was made in 1884 by G. Bardet. 1 The direct 
contact of the lower metal piece of the electrode with the inner 
wall of the stomach irritates only a small spot, and this very 
intensely, whereas the larger part of the stomach receives but 
very little of the electricity produced; in consequence thereof 
the galvanic current could not be applied, because by the usual 
method it would not be possible to avoid lesions of the mucous 
membrane of the stomach. In order to overcome these draw- 
backs Bardet constructed his stomach electrode in such a way 
that the metal piece running through the tube was shorter than 
the tube, and did not touch its windows. By filling the stom- 
ach with water the electric current between the stomach wall 
and the lower metal piece of the electrode was established. In 
this way the electricity was distributed over the whole surface 
touched by the water. By means of this electrode Bardet 
treated three cases of dilatation of the stomach, and one case of 
obstinate vomiting, with the galvanic current (15 to 25 milliam- 
peres) and obtained splendid results. Most authors who 
employed the direct electrization of the stomach have, until 
recently, generally used Bardet's electrode. (Charles G. 
Stockton's 2 stomach electrode does not differ very much from 
that of Bardet.) 

Although the high value of the direct electrization of the 
stomach is self-evident, this method did not enter much into 
practice, because the tube surrounding the electrode had to be 
kept In the throat during the whole electric session (about ten 
minutes) and inconvenienced the patient to such a. degree that 
the procedure could be carried out only in people accustomed 
to lavage of the stomach, and even by them is was disagreeably 
felt. That is the reason why von Ziemssen 3 rejected direct 

: Bardet: Bull. Gen. de Therap., 1884, tome 106, p. 529. 

2 Chari' G. Stockton: "A New Gastric Electrode," Medical Record, 

tuber 9rh. 1889, p. 530. 
•Von Ziemaa <-n: "Ueber die physikalische Behandlung chronischer 

.- und Dannkrankheiten," p. 10, Leipzig, 1888. 



174 



DISEASES OF THE STOMACH. 



electrization of the stomach as being too straining and 
Einhorn 7 s Method. 



exhausting. 



In order to facilitate the internal or direct electrization of the 
stomach I 1 have constructed an electrode on the same principle 
as the stomach bucket. This electrode once swallowed reaches 
the stomach without further artificial aid. The silk thread of 
the bucket is represented in the electrode by a very fine (1 mm. 
in diameter) rubber tube through which a very fine, soft, con- 
ducting wire runs to the battery. The end piece of the electrode 
consists of a hard-rubber capsule with many openings. In this 



Fig. 




The Deglutible Stomach Electrode (Einhorn). 



capsule lies a metallic button which is connected with the wire. 
(Fig. 69 shows the electrode in natural size.) 

The rubber capsule serves to avoid the direct contact of the 
metal with the stomach wall; the circuit is completed by the 
water the stomach contains. 

This electrode I have termed "Deglutible Stomach Elec- 
trode." 2 

Method. — The patient drinks, best when in a fasting condi- 
tion, or one to two hours after a light breakfast, one glassful of 
water, tea, or coffee. The patient has now to open his mouth 

1 Max Einhorn: Medical Record, May 9th, 1891. 

2 The Deglutible Stomach Electrode is manufactured by George Tie- 
mann & Co. 



LOCAL TREATMENT OF THE STOMACH. 175 

widely, and the electrode (the capsule piece) is placed far behind 
on the root of the tongue and he is ordered to swallow. He 
again drinks some water, and the electrode finds its way to the 
stomach without any further assistance. 

In order to recognize this point precisely, it is advisable to 
make some mark on the tubing at a distance of 40 cm. from the 
capsule; as soon as this mark comes to the teeth we are sure that 
the electrode is in the stomach and we can apply the electricity 
to the patient. 

According to my belief, it is of importance to apply gastro- 
electrization according to a certain plan. Thus it will not 
appear superfluous to give a detailed description of the electric 
application I 1 generally employ. 

The patient, when the deglutible electrode is within the 
stomach, opens his clothes, so that the abdomen is accessible. 
The key of the deglutible electrode is connected with the cord 
(negative pole) running to the battery. 

Gastrofaradization. — Sitting, ten minutes; at first large plate 
electrode at the gastric and epigastric region for five minutes, 
then a small ordinary sponge electrode. The electrode is at 
first moved up and down from left to right in the gastric region 
(sometimes, especially when there is constipation, the electrode 
is passed over the region of the colon — ascendens, transversum, 
ndens — always beginning in the right iliac region and 
stopping at the left iliac region [duration, two minutes]) 
thereafter one proceeds from the gastric region from right to 
left to the back, and remains at the left side of the seventh 
dorsal vertebra for one minute. (At this place the current can 
be applied quite strongly, and most of the patients then experi- 
a slight sensation within the stomach; the patients find 



1 Max Einhorn: "Therapeutic Results of Direct Electrization of the 
Stomach," Medical Record, January 30th and February 6th, L892. 
'' Further Experiences with Direct Electrization of the Stomach," New York 
Me lical Journal, July 8th, 1893. 



L76 DISEASES OF THE STOMACH. 

it difficult to describe this sensation; some assert that they 
experience a dragging feeling, others a feeling of weight, and 
others again of pinching. All of them refer this feeling to the 
stomach and locate it opposite different heights of the abdomi- 
nal wall.) We then return to the front, moving the electrode 
gently up and down over the gastric region for two minutes, 
gradually decreasing the current, and thus ends the sitting. 
The current has to be of such a strength that it causes distinct 
contractions of the abdominal walls; but it is not well to have 
it so strong that the patient experiences pains. 

Gastrogalvanization. — Negative pole within the stomach; 
small sponge electrode. Duration, eight minutes. First, two 
minutes below the ensiform process (during the first minute the 
current is gradually increased to its necessary strength), then 
for three minutes moving the electrode up and down the gastric 
region. After this, we then go to the back and remain one 
minute at the left side of the seventh dorsal vertebra, return to 
the front, move the electrode around the gastric region for one 
minute, and remain then quietly for one minute below the 
ensiform process. During this time the current is gradually 
weakened and the sitting is ended; the strength of the current 
is ordinarily fifteen to twenty milliamperes. 

In withdrawing the electrode a resistance is felt at the intro- 
itus oesophagi; it is not advisable to pull the electrode with force. 
One has only to make the patient swallow once or twice, and 
to make use of the moment when the larynx, by this act, ascends 
and the passage becomes free, to withdraw the electrode, which 
is done now with perfect ease. I ordinarily apply the electriza- 
tion every other day during the beginning of treatment; after- 
ward — i.e., after the lapse of two to three weeks — twice weekly 
for about three weeks, and thereafter once a week for some time. 
As a rule, I begin to decrease the frequency of the sittings when 
I notice a decided improvement in the condition of the patient. 
Even after a complete disappearance of the symptoms it is 



LOCAL TREATMENT OF THE STOMACH. 177 

advisable to continue the electrization (once a week) for some 
time. 

Direct electrization of the stomach by means of the deglutible 
electrode is very simple and handy for the patient and for the 
physician, and, as it seems to me, as easy to apply as percutane- 
ous electrization. After the first application the insertion of 
the electrode is much easier, the patient being accustomed to 
the procedure. 

The principal advantage of the deglutible electrode consists, 
firstly, in that we are able to apply the method in persons not 
used to the stomach tube, and, secondly, in that the thin cord 
does not cause any uncomfortable feeling to the patient during 
the entire electric sitting and does not provoke salivation. 
Another advantage lies in the circumstance that the deglutible 
electrode can be swallowed even in those cases in which ulcer of 
the stomach is suspected, whereas the old stomach electrode 
could not be introduced in them for fear of causing per- 
foration. 

By means of the deglutible electrode a regular course of 
electric treatment of the stomach becomes possible in many 
cases and is facilitated in all. 

I have made an extensive study of the physiological effects 
of direct electrization of the stomach and have published the 
results in several papers. From my experiments it follows 
conclusively: 

1. Direct faradization of the stomach increases gastric secre- 
tion (a) during the application of electricity and also (6) for a 
short period afterward. 

2. Direct galvanization of the stomach with the negative 
pole within the organ in most instances diminishes gastric 

retion. 

3. Direct faradization as well as galvanization of the stomach 
increases the absorbent faculty of the stomach. 

As regard- therapeusis I fame to the following conclusions: 



178 DISEASES OF THE STOMACH. 

1. Direct gastro-electrization is a potent agent in the field of 
chronic (non-malignant) diseases of the stomach. 

2. Direct gastrofaradization proves to be useful in many 
ways in most chronic diseases of the stomach. The favorable 
results appear very clearly and pretty quickly in those cases of 
stomach dilatation which are not caused by any obstruction of 
the pylorus, but merely by the relaxation of the muscular coat 
of the stomach. Here the gastrofaradization is beneficial, no 
matter whether in these cases there is hyperacidity or subacidity 
of the stomach contents. Cases of relaxation of the cardia 
(eructations), and also of relaxation of the pylorus (presence of 
bile secretion in the stomach), were very favorably influenced 
by faradization. Here the result was most markedly pro- 
nounced, inasmuch as, besides the subjective amelioration of 
the patient, the objective examination showed at the same time 
the absence of bile in the stomach contents. 

3. Gastrogalvanization is almost a sovereign means for com- 
bating severe and most obstinate gastralgias, no matter 
whether their origin is of a nervous nature or caused by a 
cicatrized ulcer of the stomach. 

4. Gastrogalvanization exerts also a favorable influence on 
several affections of the heart complicated with gastralgia. 

With regard to the effects of the current in diseases of the 
stomach, it is very difficult to give a full theoretical explanation. 
I perfectly agree with Stockton, 1 who says: 

" Exactly what role is played by faradization I am unable to 
state; whether it is a gastric sedative or a gastric stimulant I 
do not know. My efforts were in the direction of study, and 
the results were so favorable that I applied faradism to cases 
seemingly contradictory in character, and I have concluded that 
the great variety of gastric neuroses depend upon a common 
cause — an imperfect innervation of the stomach; that electric- 

1 Charles G. Stockton: "Clinical Results of Gastric Faradization." 
American Journal of the Medical Sciences, 1890, p. 20. 



LOCAL TREATMENT OF THE STOMACH. 179 

ity improves this innervation, thereby relieving the cause and 
so the conditions which, at first thought, are so contradictory." 

In therapeusis the chief factor in determining the efficacy of 
any means of treatment is and will be our empirical experience. 
For this reason I do not think it necessary to go into further 
details of the manner in which electrical currents act upon the 
human organism. The very numerous successful results 
obtained by this method of treatment warrant its general use 
in practice. 

Since the publication of my papers on direct electrization of 
the stomach man} r authors in this country as well as in France 
and Germany have made use of this method of treatment and 
highly recommend it. Thus Stockton, Ewald, Rave/ A. A. 
Jones, 2 D. D. Stewart, 3 Rosenheim, 4 Brock, 5 Goldschmidt, 6 
J. G. Wells and Levy, 7 and others have published good results 
obtained by intragastric electrization. Ewald approves of the 
shape and form of my electrode, but finds it difficult to intro- 
duce it into the patient's stomach. For this reason he has 
modified my electrode by using a thicker rubber tubing around 
the wire: the tubing corresponds to No. 13 Charriere and is 
about 1J mm. thick. I have not found, however, that the 
insertion into the stomach of the deglutible electrode offers any 
difficulties 

The principal point is to put the electrode far back into the 
pharynx and to let the patient meanwhile drink something. 



1 J. Rave: " Contribution a l'etude du traitement des dyspepsies par 
I'61ectricit6," Paris, 1893. 

- Allen A. Jones: Medical Record, June 13th, 1891. 

3 D. D. Stewart: Therap. Gazette, 1893, ]>. 744. 

* Rosenheim: Berliner Klinik., .May, 1894. 

' Brock: Therap. Monatshefte, L895, ]>. 27."). 

'Goldschmidt: "Ueber den Binflusa der Blektricital auf den gesundea 
und krankf-n menschlichen ftfagen." Deutsch. Arch. f. klin. Med., vol. 
xv.. ],. 295. 

r. Wells and L. H.Levy: "The Use of Electricity in Chronic Disorders 
Stomach." Medical Record, Feb. 4th, 1911. 



ISO DISEASES OF THE STOMACH. 

It is advisable to have the patient drink slowly about a glassful 
of water, and to have a talk with him, in order to distract his 
attention from the procedure. The electrode usually soon 
reaches the stomach, and it seldom happens that it remains 
lying in the fauces. If this does happen, the patient must eat 
a small piece of bread and drink some water; the electrode will 
then find its way into the stomach with the bread. 

If in a very rare case the deglutible electrode cannot be intro- 
duced, there is yet always time to use instead the electrode as 
modified by Ewald. 

YVegele 1 has lately devised a new gastric electrode which he 
terms the spiral electrode. Inasmuch as this electrode has to 
be used through a stomach tube, it has no advantage whatever 
over the ordinary stomach electrodes formerly in use, as the 
principal progress achieved by means of the deglutible electrode 
is that the stomach tube can be dispensed with in the applica- 
tion of electricity. 2 

List of Instruments, Apparatus, and Chemicals Required. 
Instruments. 

Stomach tube, with glass tube at- Einhorn's deglutible electrode. 

tached. Einhorn's gastrodiaphane. 

Funnel apparatus for lavage. Einhorn's cesophagoscope. 

Leube- Rosenthal's apparatus for Einhorn's stomach powder blower. 

lavage. Einhorn's gastric douche. 

Einhorn's gastric spray apparatus. Faradic, galvanic, and cautery bat- 
Einhorn's stomach bucket set. teries. 

Einhorn's duodenal bucket set. 



1 Wegele: Therap. Monatshefte, 1895, p. 195. 

2 Internal massage of the stomach has been recently suggested by Dr. 
Fenton B. Turck, of Chicago, 111., by means of his "gyromele" or "revolv- 
ing sound." This instrument consists of a flexible cable, to the end of which 
is attached a sponge covering a spiral spring, which can be removed from the 
cable at will and changed. The cable passes through a rubber tube, and 
this again is attached to a revolving apparatus, for the purpose of producing 
revolutions of the sponge. (See American Medico-Surgical Bulletin, July 
1st, 1895.) 



LOCAL TREATMENT OF THE STOMACH. 181 

Apparatus. 

Three wide-neck bottles. Two beakers. 

Three flasks, Erlennieyer's form. Two graduated cylinder glasses (1-5, 

Three glass funnels. 1-10 c.c.). 

One burette (10-50 c.c); burette Two porcelain dishes. 

support. One alcohol lamp. 

Two glass rods. Test tubes. 

Chemicals. 

Litmus and Congo paper; filter paper; Gunzburg's solution (phlor- 
glucin 2. vanillin 1, alcohol 30). Methyl violet; phenolphthalein (one- 
per-cent. alcoholic solution); Toepfer's solution (dimethyl-amido-azo- 
benzol, 0.5-per-cent. alcoholic solution) ; decinormal solution of sodium 
hydrate; liq. natr. hydr. (1:15); sulphate of copper (one-per-cent. solu- 
tion); saturated solution of sodium chloride; Lugol's solution (iod. 0.1, 
3. iod. 0.2. aq. dest. 200.0); carbolic acid (two per cent.); liq. ferr. 
sesqiiichlorat.; acetic acid (two per cent.); ether; chloride of calcium: not 
saturated solution. Barium carbonate; calcium carbonate, powdered, 
chemically pure. Benzidin test paper ; Benzidin ; glacial acetic acid ; peroxide 
of hvdrogen. 



CHAPTER V. 

ORGANIC DISEASES WITH CONSTANT 
LESIONS. 

The Acute and Chronic Gastric Catarrh. 
1. Acute Gastritis. 

Stjnonyms. — Gastritis glandularis acuta; acute gastric cat- 
arrh; catarrhus ventriculi acutus. 

Definition. — An inflammation of the gastric mucous mem- 
brane, resulting in disturbances of digestion. 

Acute gastritis may be divided into the three following 
forms: Gastritis acuta simplex, gastritis-phlegmonosa, and 
gastritis toxica. 

Gastritis Acuta Simplex or Acute Gastric Catarrh. 

Etiology. — Acute gastric catarrh is one of the diseases most 
frequently met with in the practice of the physician, and occurs 
at all ages and among all classes of society. It is usually 
attributable to errors in diet, the chief cause being an abnormal 
quantity of ingesta. Irritation followed by inflammation of 
the stomach often results from the use of very hot, but especially 
ice-cold drinks, or from too highly spiced or fermented foods. 
If food be imperfectly masticated and swallowed in big lumps, 
it may mechanically disturb the stomach and lead to inflam- 
mation. The same effect is induced by irritating substances, 
as, for instance, alcohol, rancid butter, etc. 

The sensibility of the stomach is not always alike. One of 
the above-named causes may be productive of a catarrhal con- 
dition in one person, while in many others it remains perfectly 
inactive. The tendency to acute catarrh of the stomach varies 

182 



GASTRITIS ACUTA SIMPLEX. 183 

very much in different Individuals and families. Some people 
have a certain predisposition for tins affection, which is desig- 
nated by the expression "delicate stomach." The latter is 
often found in anaemic women, in old persons, and invalids of 
all kinds. The question whether the acute gastric catarrh may 
originate by way of infection has not as yet been settled. The 
epidemic appearance of this affection at a certain time speaks 
in favor of such an assumption, which was first propagated by 
Lebert 1 and Oser. 2 Xo micro-organisms, however, have been 
found within the stomach wall to corroborate this theory. 
Besides the above named direct causes, acute gastric catarrh 
is indirectly engendered by all acute infectious diseases, which 
it ordinarily accompanies. 

Morbid Anatomy. — As gastritis as such hardly ever causes 
death, and inasmuch as the stomach after death quickly under- 
- radical changes which destroy the true picture that had 
before existed, the minute histology of the affected stomach can 
be studied only with the greatest difficulty. Even nowadays 
we have no better description of the macroscopical aspect of the 
inflamed organ than that given nearly eighty years ago by 
Beaumont 2 from his observations made on the well-known 
Canadian St. Martin with his gastric fistula. The mucous mem- 
brane appears entirely or partially swollen and reddened and 
is marked here and there with small sacculations. Less gastric 
juice is secreted, and mucus covers the surface. The pyloric 
porti' rule, is more affected, and there exist more or less 

extensive extravasations of blood. The secretion is only 
weakly acid or neutral, or even alkaline. 

Microscopically the principal cells are found to be more 
granular and cloudy, partly fatty and shrunken. There is no 



\)\o Krankheiten dea Magens," TQbingen, L878, p. 29. 
_ nkrarikhfiten." Eulenburg'fl "Realencyclop»dia," vol. 
xii.. ]>. 110. 

* Beaumont ; I. c. 



184 DISEASES OF THE STOMACH. 

distinction possible between the parietal and the principal cells. 
In the interglandular tissue numerous round cells are found. 
They are also met with between the epithelial cells and appear 
to be wandering to the surface. These round cells, according 
to Sachs, 1 gives distinct pictures of karyokinesis. 

Symptomatology. — Immediately after a manifest indiscretion 
of diet there is experienced, first of all, a feeling of heaviness at 
the pit of the stomach; later on a sensation of fulness. There 
is a desire to belch, and a difficulty in doing so. After belching, 
the patient feels easier for a little while, but soon the heavy sen- 
sation reappears. This condition may persist unchanged for 
a few days, and then gradually disappear. This is the mild 
form of the acute catarrh. Very often, however, we meet with 
more alarming symptoms. At the beginning there may exist 
nausea, a sensation of weight, and slight pains in the gastric 
region, severe headache, sometimes rise of temperature, later 
on vomiting, extreme anorexia, constipation, or diarrhoea. 
Soon the symptoms become less severe, and appear as described 
in the milder form. 

Objectively the gastric region appears bloated, and is sensi- 
tive to pressure. The tongue is thickly furred, and the taste 
pappy. If vomiting occurs, the ejected matter contains no free 
hydrochloric acid, is of a slightly acid or neutral or alkaline 
reaction, and is frequently mixed with a great deal of mucus. 

The duration of the affection is short, as a rule from one to 
three days. The more severe cases begin with a sudden rise 
of temperature (102° to 104° F.), which may be accompanied 
with chills. In such instances the gastric symptoms may at 
first be less marked than the symptoms caused by the fever. 
After a short period, however, the gastric symptoms become 
more pronounced. 

1 A. Sachs: "Zur Kenntniss der Magenschleimhaut in krankhaften 
Zustanden." Arch. f. experim. Pathologie, Bd. 22, Heft 3, and Bd. 24, 
Heft 1 and 2. 



GASTRITIS ACUTA SIMPLEX. 185 

The inflammatory process of the stomach not rarely extends 
into the intestines, and then causes constipation or diarrhcea. 
The affection may also invade the gall bladder, and then give 
rise to icterus. In the febrile form of gastritis, herpes labialis 
is of frequent occurrence. 

Diagnosis. — It is easy to make the diagnosis in those cases 
which are not accompanied by fever, and where the cause of 
the trouble is apparent. The analysis of the gastric contents or 
of the vomited matter shows a marked diminution in the secre- 
tion of gastric juice. An acute gastritis accompanied by fever 
will at times cause some difficulty in diagnosis. As is well 
known, most of the infectious diseases are accompanied by gas- 
tric catarrh at their commencement, but they can be easily 
excluded by the absence of then pathognomonic symptoms. 
It is less easy to make a differential diagnosis between a begin- 
ning typhoid fever and acute gastric catarrh. In fact, the 
distinction between these two conditions is sometimes almost 
impossible during the first and second days of the sickness. 

The following may serve as differential points of diagnosis 
between these two conditions: 

In typhoid fever the temperature is characterized by its 
gradual rise, while in gastric catarrh the rise of temperature is 
quite sudden; we may have at the very start a temperature of 
103° or 104°. The remission in gastric catarrh will likewise be 
more pronounced. The presence of herpes labialis will speak in 
favor of gastric catarrh, while the appearance of Ehiiich's 
diazo reaction in the urine will point to typhoid fever. The 
presence of Widal's reaction will also speak for the latter 
affection. 

Biliary calculi not causing very severe pains, and not accom- 
panied by icterus, may sometimes be mistaken for a gastric 
catarrh. Such an error in diagnosis will, however, occur but 
seldom; as a rule, it is easy to differentiate between these two 
conditions. 



ISO DISEASES OF THE STOMACH. 

Prognosis. — The prognosis of gastric catarrh is very favorable, 
except in cases of very old people and invalids, in which the 
process may cause serious complications. 

Treatment. — This vis medicatrix natural is best seen in this 
affection. In order to become freed of the undigested material, 
the stomach empties itself either by vomiting or transferring 
its contents into the small intestine, which in turn gets rid of 
them by diarrhceal passages. The anorexia prevents the 
patient from taking food, and in this way the stomach can 
enjoy perfect rest and soon recuperate. 

In our treatment we have to imitate or rather assist nature. 
If spontaneous vomiting does not take place, and a feeling of 
pressure and pains in the stomach are present, if percussion over 
the gastric region gives dulness, and belching of badly smelling 
gases occurs, then we may be certain that all the symptoms 
mentioned are caused by decomposed food within the organ. 
Here it is best to look for means which will remove this obnox- 
ious material. Washing out of the stomach is the best way to 
accomplish this end. Instead of lavage, however, we may tell 
the patient to chink half a pint or even a pint of lukewarm 
water in which a small quantity ef table salt has been dissolved, 
and then tickle the throat with the end of a quill or with the 
finger in order to produce vomiting. Camomile tea can also be 
taken in the same manner before bringing on vomiting. 

Emetics are rarely given nowadays. In suitable cases it is 
best to make use of the subcutaneous injection of apomorphine 
(the dose being about one-half a centigram). Tartar emetic 
and ipecacuanha should never be employed except in children. 
The stomach after having been emptied should now enjoy 
perfect rest for some time. Thus during the first or second day 
of illness it is best not to give the patient anything substantial 
to eat. Strained barley or rice water or weak tea may be 
taken. On the third day, as soon as the appetite reappears, 
the patient is permitted to partake of a water soup (bread and 



GASTRITIS PHLEGMOXOSA. 187 

hot water), of oatmeal or barley gruel, rice soup, and perhaps 
one soft-boiled egg. Later on French bread, butter, and oysters 
may be added to the dietary. If the improvement is steadily 
progressing, we begin on the fourth day with meat once a day, 
and thus slowly return to the usual bill of fare. As a rule, no 
medicines whatever are needed. If obstinate constipation 
exists, however, and the bowels have not moved during the 
first two days of sickness, some aperient may be given. A 
large dose of calomel (ten to fifteen grains) administered once 
is very serviceable. This remedy should especially be employed 
in the febrile form of gastritis. If there is no fever, Seidlitz 
powders or a good dose of citrate of magnesia will serve the 
purpose. 

In rare instances in which the symptoms appear in a very 
aggravated form they may require special attention. A pro- 
nounced sensation of pressure and fulness in the gastric region 
after the ingestion of food may be relieved by small doses of 
dilute hydrochloric acid (ten drops in a glassful of water three 
times daily half an hour after meals). 

A high degree of pyrosis can be relieved by the following 
medication: 

P Calcined magnesia, 

Sodium bicarbonate, 

Peppermint sugar, aa 10.0 

If. f. pulv. D. ad scatulam. S. A point of a knife every two 
hour-. 

Severe pains may be relieved by a small dose of codeine: 

R Codein. phosph 0.1 

Aq. menth. pip 40.0 

3. « 'in- teaspoonful twice or three times daily. 

( }a stritis Phlegmonosa. 

onyms. — Gastritis phlegmonosa purulenta; purulent in- 
flammation of the stomach. 
1 his affection usually runs an acute, and very rarely subacute 



1SS DISEASES OF THE STOMACH. 

course. The inflammatory process is situated in the sub- 
mucous and muscular layers of the stomach, differing in this 
respect from acute gastritis, in which the glandular layer is 
affected. Phlegmonous gastritis is a very rare disease and 
occurs more frequently among men than women. Two forms 
of this affection are met with: the primary or idiopathic and 
the metastatic. Although the exact cause of primary purulent 
gastritis is as yet unknown, the symptoms and course of the 
morbid process justify the assumption that it is due to some 
micro-organism. The metastatic form occurs in pyaemic and 
puerperal fever or severe exanthemata. 

Morbid Anatomy. — There may be present either a circum- 
scribed abscess in the gastric wall (gastritis phlegmonosa cir- 
cumscripta or abscess of the stomach), or a diffuse purulent 
infiltration. In the latter instance, numerous small abscesses 
of pea or hazelnut size are generally found. The mucosa over 
these areas appears swollen. The abscesses lie in the submu- 
cosa or muscularis and often extend to the serosa. If the 
purulent process progresses further, perforation may occur either 
into the stomach or into the abdominal cavity. 

Symptomatology. — After the existence of dyspeptic symp- 
toms for some time, or without any previous disturbances, 
the patient suddenly experiences an intense pain in his gastric 
region. At the same time there appear a violent burning sen- 
sation within the stomach, extreme thirst, dry tongue, and 
perfect anorexia. These symptoms are accompanied by high 
fever (103°-105° F.), with only very short intermissions. 
Sometimes the onset of the disease is attended by chills. The 
pulse is small and irregular. In most instances there is vomit- 
ing and retching, the vomited matter consisting mainly of 
mucus and some bile. The gastric region is very painful to 
pressure. The bowels are either constipated, or (as is generally 
the case) diarrhceal. The disease, as a rule, ends fatally in a 
very short time (four to seven days). It may, however, last 



GASTRITIS TOXICA. 189 

fourteen days. The chronic form occurs most frequently in 
the course of the so-called gastric abscess. 

Diagnosis. — An exact diagnosis of this affection can hardly 
be made dining life. If, in connection with the above symp- 
toms, there is an increased resistance in the gastric region 
with severe pain on pressure, we should think of purulent 
gastritis. 

Treatment. — The treatment should be symptomatic. Ice- 
cold application to the abdomen, leeches, large doses of opium, 
or subcutaneous injections of morphine, and, if there is collapse, 
camphor, ether, and the like will have to be administered. 

Gastritis Toxica. 

Among the poisonous substances which directly affect the 
gastric mucous membrane, the following deserve special notice: 
Alcohol, phosphorus, arsenic, potassium cyanide, corrosive 
sublimate, nitrobenzol, potassium chlorate, concentrated min- 
eral acids (sulphuric acid, nitric acid), and the caustic alkalies. 
The first-named substances cause an intense acute gastritis. 
The mucous membrane becomes swollen and superficially 
necrotic, leaving behind small hemorrhagic spots. Microscop- 
ically the glandular tubuli are found to have undergone fatty 
degeneration. The latter group of poisons (acids and alkalies) 
act quite differently. They directly destroy the parts they 
come in contact with and in this way the whole mucous layer 
may become destroyed; sometimes, should the poison penetrate 
still farther, the submucosa may also be destroyed, and rupture 
of the stomach takes place. 

Symptomatology. — The symptoms will be more or less marked 
according to the quantity of poison taken. There is always 
pain in the gastric region, which is increased on pressure. 
Vomiting is of very frequent occurrence. The vomited matter 
may contain an admixture of blood. Thirst is always present. 
In cases of a severe nature there is always found a small pulse, 



190 DISEASES OF THE STOMACH. 

cyanosis, cold perspiration, slight coma, and death may occur 
in collapse. 

In other cases the course may be somewhat more protracted 
and either peritonitis or icterus, hematuria caused by the poison 
circulating in the blood, may develop. In those instances in 
winch death does not occur there may arise — after the acute 
symptoms of poison have been subdued — a condition which is 
similar to that of a subacute gastritis. 

It sometimes, though seldom, happens that the mucous 
membrane of the stomach is affected to such a high degree that 
it may entirely atrophy and then a condition of achylia gastrica 
will result. In cases of poisoning by mineral acids or caustic 
alkalies, it may occur that in consequence of the sloughing of 
an area situated either near the cardia or near the pylorus a 
stricture develops, thus causing serious complications. These 
strictures frequently develop later on, at a time when the 
patient perhaps imagines that he is entirely rid of his trouble. 
The stricture of the cardia causes dysphagia, and the stricture 
of the pylorus ischochymia. 

Diagnosis. — The diagnosis is frequently made by the cross- 
examination of the patient, provided he is able to state what 
kind of poison he took. The inspection of the mouth, tongue, 
and pharynx may lead us to suspect poisoning by mineral acids 
or caustic alkalies, as both cause manifest lesions (sloughing) 
at these places when taken. The examination of the vomited 
matter will also frequently lead us to discover the nature of the 
poison. 

Prognosis. — The prognosis will greatly depend upon the 
quantity of poison taken, and upon the condition in which we 
find the patient. On the whole, every case of poisoning must 
be considered as quite serious, recovery being doubtful. 

Treatment. — In all cases of poisoning by concentrated mineral 
acids and caustic alkalies, the best mode of treatment is to 
effect dilution of the poison, and if possible its neutralization. 



CHRONIC GASTRIC CATARRH. 191 

Thus we give calcined magnesia (100 gm. dissolved in a pint of 
milk) to the patient as a chink in case the poison consisted of 
a mineral acid; the magnesia will then neutralize the acid. 
On the other hand, we administer a chink consisting of lemon- 
ade or a weak solution of acetic acid (one to two per cent.) in 
case the poisonous substance has been a caustic alkali, for the 
reason that the acid introduced forms a harmless combination 
with the poison. In the instances just mentioned, lavage can- 
not be used for fear of a perforation of the stomach; nor is it 
permitted to bring on vomiting, as the poisonous matters lodged 
within the stomach would cause a great deal of harm by their 
coming in contact with the oesophagus and mouth when ejected. 
In all other kinds of poisoning (alkaloids and metals) it is 
always best to use lavage as early as possible, in order to free 
the stomach and the organism of that portion of the poison 
that has not yet entered the small intestine. Although an 
emetic (like apomorphine) can be used for this purpose, siphon- 
age of the stomach is, however, by all means preferable, for 
only the latter permits a thorough emptying and cleaning of the 
organ. It is not the place here to speak of all the antidotes 
that have to be employed in these cases. The subsequent 
treatment will always depend upon the symptoms in each given 
ease. In peritonitis ice will have to be applied on the abdomen, 
and opiates freely given. The treatment of a resulting stricture 
of the cardia or of the pylorus must, in most instances, be a 
surgical one. In the former cases, dilating of the cardia by 
means of bougies will first be tried. 

2. CJrronic Gastric CatarrJt — Gastritis Glandularis Chronica. 

Definition. — Chronic inflammation of the gastric mucous 
membrane, causing various disturbances in the act of digestion. 

Pathological Anatomy. — The mucosa is usually covered with 
a thick layer of tenacious mucus presenting a yellowish-gray or 
Blate-gray color, while some parts may appear intensely red. 



192 DISEASES OF THE STOMACH. 

The latter condition is frequently found in the secondary cat- 
arrh caused by congestion. The mucosa is frequently thicker 
than normally, and forms papillary projections, thereby causing 
the so-called etat mamelonne. 

As a rule, the pyloric portion of the stomach is chiefly 
involved. The inflammatory process, however, may some- 
times extend over the entire mucous membrane. In some 
instances the submucosa and muscularis may also undergo 
some changes, and appear either in a hypertrophied state or 
very much atrophied. Microscopically the glands often seem 
enlarged, sacculated, and dilated in cyst-like forms. The 
tubuli have lost their normal regular arrangement and show an 
atypical ramification. The glandular cells appear granular and 
in a condition of fatty degeneration, and there is no longer any 
difference recognizable between the principal and parietal cells. 
An abundant small-celled infiltration is present which fills the 
interglandular spaces and pushes the glands apart. This small- 
celled infiltration is especially marked near the surface of the 
mucous membrane. The superficial layer of the epithelium of 
the mucosa is frequently defective. The mouths of the glands 
are very often filled with a pale mucous mass, which projects 
against the lumen without any enclosing membrane. According 
toEwald, 1 there is a condition of mucous catarrh in which the 
degeneration may be observed to extend down to the base of 
the glands, so that in place of the ordinary principal and parie- 
tal cells we find cells in the most varied stages of mucoid degen- 
eration. This condition is especially found in the pyloric 
region. Some cells may be found which are still intact, the 
mucus filling only a small part of them, while the rest of the cell 
is occupied by granular protoplasm and a large nucleus. In 
others the mucus occupies the greater part of the cells and 
crowds the protoplasm and the flattened nucleus against its 
base; in still others the cell membrane has ruptured, and the 

1 Ewald: I. c, p. 318. 



CHROXIC GASTRIC CATARRH. 193 

mucus has escaped into the lumen of the duct of the gland. 
This mucoid degeneration Ewald found only in specimens which 
had been placed while still warm in alcohol. In older speci- 
mens the condition above described could not be discovered. 
In a patient with cancer of the pylorus, I had the opportunity 
to find in the wash-water a small piece of the gastric mucosa. 
It was placed in alcohol at once, and the microscope revealed 
a beautiful picture of mucoid degeneration (see Fig. 50). 

The inflammatory process after existing for a long period 
may at the end lead to a total destruction of the glandular layer 
of the entire organ, thereby causing a condition which has been 
termed atrophy of the stomach or anadenia ventriculi (Ewald). 
Two different processes ultimately effect this condition. 

The first consists in a fatty degeneration and destruction of 
the gland, the process progressing from the surface of the 
stomach inwardly. While in the early stage no glands are 
found on the surface of the mucosa, there still exist glandular 
situated near the submucosa. Later on even these gland- 
ular cysts disappear, and the whole mucosa consists almost 
entirely of round cells. According to Ewald, this process is 
daily met with in those instances in which the entire organ 
i- more or less dilated and the walls thin. The submucosa is 
then also partly changed, the muscular layer being much 
thinner. 

The second process takes its origin in the submucosa, and 

- from the deeper layers to the surface of the stomach. 

In this instance the fibrous elements play the greater part. 

The inflammatory process causes the formation of fibrous tissue, 

which spreads around the glands and partly constricts them. 

The glands are also ultimately destroyed and their place taken 

up by fibrous tissue. As a rule this condition is found in 

ache which are much smaller than usual, and present a 

thir-kenin^r f their walls. The size of the organ in such in- 

Btances may be reduced to that of a big pear, and the walls 

13 



194 



DISEASES OF THE STOMACH. 



may attain a thickness of about 1 to 2 cm. Brinton 1 has termed 
this condition "cirrhosis ventriculi," while the French desig- 
nate it " sclerosis ventriculi." This condition of cirrhosis ven- 
triculi, however, may be associated with the first-described 
process, as the following drawing of a case I have observed 
clearly illustrates. 




Fig. 70.— Cross-Section through the Stomach Wall (of A. G., with achylia gastrica), 
showing relations of the layers; a, mucosa; b, submucosa; c, d, muscularis; e, serosa. No 
glands in the mucosa. X60. 

Etiology.— Chronic gastric catarrh is more frequently met 
with among men than among women. It is often caused by 
an irrational mode of living. Fast eating, resulting in imperfect 
mastication of the food; overloading the stomach with too 

1 W. Brinton: "Diseases of the Stomach." 



CHRONIC GASTRIC CATARRH. 195 

large quantities of food; highly spiced dishes; ice-cold drinks — 
all these tend to irritate the stomach, and to cause a catarrhal 
condition of the organ. In this country ice water and fast 
eating are the two principal causes of the so-called "American 
dyspepsia." Tea and coffee taken in too large quantities are 
also said to cause tins trouble. Alcoholic drinks, especially the 
stronger ones, as whiskey or liquors (among them also stomach 
bitters), and the abuse of tobacco (smoking and chewing, 
especially the latter) also frequently give rise to this affection. 
But even in people leading a regular life chronic gastric catarrh 
may develop, either after frequently repeated attacks of the 
acute form or after the recovery from very severe infectious 
diseases. Thus typhoid fever is frequently found to be the 
origin of the affection. An unhealthy condition of the mouth, 
and more so of the teeth is liable to produce gastritis; for in 
these instances the food on the one hand cannot be chewed 
thoroughly, on the other hand it becomes impregnated with 
products of decomposition originating from decayed teeth, and 
in this way produces an undue irritation of the gastric mucous 
membrane. Chronic gastric catarrh is moreover found as a 
secondary disorder in association with many other chronic 
thus, for instance, all kinds of pulmonary and cardiac 

Li >ns, liver and kidney troubles, are frequently found to be 
complicated with chronic gastritis. Likewise some constitu- 
tional dis< - for instance gout and diabetes, are frequently 
combined with gastritis. 

nptomatology. — As a rule the disease develops very slowly. 

The initial symptoms arc not well marked. After the condition 

1 for a longer period of time the disturbances become 

more pronounced, and a train of many varied symptoms is 

present. The patients frequently complain of an abnormal 

in their mouths. They describe it either as salty or as 
pappy, in a few instances as sour. The appetite is ordinarily 
diminished, or, if present, the feeling of satiation appears after 



196 DISEASES OF THE STOMACH. 

a few morsels of food. After meals there is a sensation of ful- 
ness in the gastric region, and the patient feels oppressed. 
This feeling, if present in a higher degree, sometimes gives rise 
to symptoms of quite an alarming nature. Thus the patients 
complain of palpitations of the heart and shortness of breath 
(asthma dyspepticum). In some instances again there appears 
a dizzy feeling, winch is occasionally so severe that the patient 
cannot occupy a standing position but has to sit down or lie 
down. The oppression experienced is relieved by belching, but 
the latter may occur so frequently as to greatly annoy the 
patient. In fact, belching constitutes one of the most frequent 
symptoms of chronic gastric catarrh. As a rule, a quantity of 
odorless gas is brought up by the act of belching, although in 
very rare instances it may have an unpleasant odor. 

Pain. — As a rule intense pains are absent. There is a mere 
sensation of discomfort and sensitiveness in the gastric region, 
winch may increase after meals, more especially after ingestion 
of coarse food. 

Pyrosis. — The patient may experience a burning sensation 
at the pit of the stomach. In this instance a sour liquid, alone 
or mixed with food, often comes up through the oesophagus 
into the mouth (regurgitation) . 

Vomiting. — Vomiting is not of very frequent occurrence in 
gastric catarrh. It is met with most frequently after the 
morning meal or in the morning on arising. In the latter 
instance the quantity ejected is quite small, and consists of a 
watery fluid containing principally mucus. A feeling of nausea 
is more frequently observed. 

Condition of the Bowels. — The bowels are frequently found 
abnormal: either they are very constipated, which is quite the 
rule, or there may exist diarrhoea, or again periods of diarrhoea 
may alternate with periods of constipation. 

Urine. — The urine is scanty, and frequently contains deposits 
of phosphates and urates. 



CHRONIC GASTRIC CATARRH. 197 

General Symptoms. — The patients feel languid and manifest 
less energy in the performance of their work. Their mental 
activity is frequently weakened. They often complain of 
headache, especially in the morning, and a heavy feeling in the 
limbs. A desire to yawn is often met with, and some patients 
assert that they cannot breathe as deeply as they desire. In 
some instances the flow of saliva is greatly increased. Some- 
times patients experience a constant irritating feeling in the 
throat, which they seek to relieve by a kind of hacking cough. 

Objective Signs. — The general appearance of the patient is, 
as a rule, quite good. He looks well nourished, and usually 
possesses a good panniculus adiposus. Some patients, however, 
show black rings around their eyes, notwithstanding their 
being well nourished. Under these circumstances they fre- 
quently have cold hands and feet, and chill very easily. There 
are. however, exceptions to this rule, and patients are some- 
times observed who have lost considerably in weight and appear 
quite emaciated and thin. 

The tongue is, as a rule, covered with a fairly thick, grayish, 
and moist coating. The margins of the tongue show the inden- 
tations of the teeth. Either there is no offensive smell 
at in the mouth or, if it exists, it is due to some imper- 
fection in the condition of the teeth, nose, or throat. 

The gastric region often appears bloated. On palpitation it 
is found to be sensitive to pressure, although there is no real 
pain. The splashing sound can be easily produced when the 
stomach contains some liquid. The size of the organ is, as a 
rule, not increased. 

The gastric contents: One hour after Ewald's test breakfast 

ic contents show a lessened degree of acidity, and 

contain either no free hydrochloric acid at all or only small 

quantities. In rare instances an increase of hydrochloric acid 

is encountered — u acid gastric catarrh." The pieces of roll are 

normally. Pepsin and rennet are always present; 



198 DISEASES OF THE STOMACH. 

erythrodextrin is present only in small quantities, while 
achroodextrin and sugar are abundant. The quantity of the 
gastric contents obtained after the test breakfast is either 
normal or somewhat larger (120-180 c.c). Mucus may be 
present in great quantities in the gastric contents of some per- 
sons, while it may be absent in others. In the former case the 
gastritis is designated by the name of "gastritis chronica 
mucosa." The mucus in the gastric contents can be easily 
recognized by its appearance. A glass rod dipped into the 
contents and lifted in an oblique direction will cause a part of 
the mucus to be drawn up in the form of strings. The contents 
pass very slowly through filter paper, and the addition of acetic 
acid to the filtrate will produce turbidity. In the fasting con- 
dition the stomach is either found empty, or it may contain 
only a few cuoic centimetres of a turbid liquid, consisting of 
mucus, and presenting either an alkaline, neutral, or acid 
reaction. In the latter instance free hydrochloric acid may be 
discovered in small quantities. Microscopically many round 
cells and some epithelial cells are found to be present. In 
washing out the stomach in the fasting condition, the wash 
water, as a rule, contains more or less considerable quantities 
of mucus. Instead of examining the gastric contents, the 
vomited matter, if such is present, can be made use of for testing 
the chemical qualities of the gastric juice. As a rule, the same 
conditions will prevail here as stated above under the examina- 
tion of the gastric contents. 

The motor function of the stomach is either not impaired at 
all, or only slightly diminished. 

Absorption. — Most writers assert that the absorption is 
retarded. It seems to me, however, that this rule does not 
apply to all substances. On examining the absorptive power 
in several cases of chronic gastric catarrh with the potassium 
iodide test, I could not see any marked departure from the 
normal. 



CHROXIC GASTRIC CATARRH. 199 

I subjoin two cases of chronic gastric catarrh, one represent- 
ing a mild and the other a more advanced form of this affection: 

Case I. — Mrs. L. W , about 26 3 T ears of age, suffered for 

about four years from frequently recurring digestive disturbances 
(poor appetite, pains in the region of the stomach and in the 
abdomen). She had been treated by several competent physi- 
cians, sometimes with good results. Several months before 
consulting me the general health of the patient was impaired; the 
complaints, likewise, had greatly increased during the past six 
weeks. She suffered from pains in the region of the stomach, and 
could not eat sufficiently, for soon after partaking of the food she 
had a sensation of being laced; she could not sleep, and was 
troubled much with repeating and flatus; during the summer 
she lost in weight considerably. 

Status prccsens: Patient has a pale appearance and frail struc- 
ture; color of lips and cheeks pale; tongue coated; chest organs 
normal; abdominal wall relaxed; the abdomen slightly distended; 
the epigastric region somewhat painful on pressure; the splashing 
sound can be produced below the left margin of the ribs down to a 
point three fingers' width above the navel. 

One hour after the test breakfast; HC1 = 0; lactic acid + ; acid- 
ity =00; erythrodextrin + much; mucus present. 

When fasting, stomach is found empty; lavage brings up very 
little mucus. 

Treatment: Xux vomica, HC1, gymnastics, cold washing and 
rubbing of the body, and direct gastrofaradization. 

Soon after the beginning of this treatment the patient felt 

better; she could partake of more food; the pains first decreased in 

ity, and soon disappeared almost entirely. The patient 

gained during treatment (six to seven pounds) and acquired a 

healthy color. 

3B TT. — Henry K , 33 years of age, suffered for ten or 

ira from "spitting of water." By this phrase the patient 

meant t<; express the regurgitating every day, or at least every 

day, of a considerable amount of a tasteless fluid from the 

ich into the mouth, which he then expectorated. Some- 

3 this occurred teE or twelve times during the day. For the 

• or nine months the patient had this spitting after 



200 DISEASES OF THE STOMACH. 

each meal. Appetite never good, although the patient could 
partake of each meal. When a boy he was strong and stout, but 
has been thin since his twentieth year. Sleep good; bowels 
moved every other day, but not regularly. During the last 
thirteen years there has been from time to time vomiting (i.e., the 
ejection of the whole meal). Before the vomiting the patient 
has a sensation of oppression. 

The physical examination of the chest organs reveals nothing 
abnormal. The stomach reaches down to within two fingers' 
width of the symphysis, as shown by gastrodiaphany and splash- 
ing sounds. 

One hour after the test breakfast: HC1 = 0; acidity =14; rennet 
ferment + . (Similar results have been obtained by examination 
on several other occasions.) 

Course. — The duration of chronic gastritis is a very long one. 

Very frequently there are exacerbations of the symptoms, 
even when the condition was apparently almost entirely sub- 
dued. Indiscretions in diet are especially liable to cause a 
recurrence. Often, however, a rational treatment effects the 
disappearance of all the symptoms, and the condition of perfect 
euphoria may last for years and years. 

Diagnosis. — In the diagnosis of chronic gastritis the following 
points demand attention: 

1. The long and progressive course of the disease. 

2. The symptoms above described. 

3. The decreased secretion of gastric juice (low acidity), 
which in some may be combined with an undue amount of 
mucus. 

Differential Diagnosis. — It is quite easy to distinguish 
between primary and secondary chronic gastritis. The latter 
accompanies many organic diseases of vital organs. The recog- 
nition of the principal ailment shows the true nature of the 
affection. It is more difficult to differentiate between chronic 
gastric catarrh and other lesions of the stomach: ulcer, cancer, 
neurosis, achylia gastrica. Chronic gastritis is never accom- 



CHROXIC GASTRIC CATARRH. 201 

panied by very severe pains, and thus presents a contrast to 
ulcer and cancer. Absence of a circumscribed spot painful to 
pressure in the gastric region also speaks against ulcer. There 
i< no haematemesis, and as a rule no marked emaciation in 
chronic gastritis, while in ulcer and cancer these two conditions 
are frequently met with. It is (mite difficult to differentiate 
between chronic gastritis and gastric neuroses of a depressing 
nature. The symptoms may be alike in both, especially the 
diminished gastric secretion. These neuroses may sometimes 
be recognized by the discovery of other nervous symptoms. 
Sudden changes in the chemical condition of the gastric con- 
tents speak in favor of the existence of a neurosis. Changes in 
the subjective symptoms, then* entire disappearance for a few 
days, and then their sudden reappearance, either in the same 
form as before or in a changed manner, are also characteristic 
of a gastric neurosis. Chronic gastritis, on the other hand, 
shows, as a rule, more or less consistency in the conditions of 
the gastric juice as well as of the other symptoms. While 
changes in the subjective sensations of the patient may occur, 
they are. however, less abrupt and less pronounced than in the 
neurosis. Achylia gastrica is recognized by the tc tal disappear- 
anc( _ stric juice, i.e., by the absence of hydrochloric acid 
and both ferments, rennet and pepsin. Although chronic 

ritis may terminate in such a condition (a disappearance 

of juice), it is nevertheless more practical to separate achylia 

strica from gastric catarrh, as there are several other condi- 

is which lead to this affection, and as it requires a different 

•incut. 

. — The prognosis of a genuine chronic gastritis is 

bad. A rational treatment succeeds, as a rule, in either 

curing or materially improving the patient. The ailment is, 

r, by no mean- of an indifferent nature; in a certain 

~urc we can say thai the trouble is the more serious the less 
retion there is in the stomach. Very frequently we are not 



202 DISEASES OF THE STOMACH. 



able to bring back the stomach to its normal state of secretion, 
even if we succeed in combating the subjective symptoms. 
Kxacerbations and relapses are also liable to occur. For these 
reasons chronic gastritis must be considered as a tedious 
affection. 

Treatment. — The regulation of the diet is of prime importance 
in the treatment. The dietary to be selected will depend upon 
the severity of the symptoms. At the beginning, therefore, a 
light diet will be called for. The patient should partake of 
four or five meals daily. The articles of food should be given 
largely in liquid and semi-liquid form; viz., milk, kumyss, 
zoolak, barley, oatmeal, and rice soups prepared in milk; 
chicken soup, with an egg beaten up in it; soft-boiled eggs; 
mashed potatoes; scraped meat, raw or broiled; toasted bread, 
and also French white bread (not too fresh); butter; tea and 
cacao. The quantity of nourishment for each meal should 
neither be excessively large nor too small. 

Ewald's bill of fare for chronic gastric catarrh is as follows: 

Eight o'clock — 150-200 gm. of tea with 75-100 gm. of stale white bread, 
toast or zwieback. 

Ten o'clock — 50 gm of white bread, 10 gm. of butter, 50 gm. of cold meat 
or ham, occasionally one glass of light wine or one-third litre of milk. 

Two o'clock — 150-200 gm. of water, milk or bouillon of the white meats, 
100-125 gm. of meat or fish, 80-100 gm. of vegetables, 80 gm. compot. 

Four or five o'clock — one-fourth to one-third litre of warm milk (occa- 
sionally mixed with cacao or coffee). 

Seven to eight o'clock — 200 gm. of soup or pap, 50 gm. of white bread, 10 
gm. of butter. 

Occasionally at ten o'clock — 50 gm. wheaten bread (biscuits or zwieback), 
one cup of tea. 

My own bill of fare for the first week of treatment is as 
follows: 

Eight O'clock: Calories. 

Two eggs, 160 

Two ounces of French white bread, 156 

One-half ounce of butter, 107 

One cup of tea (100 gm. of tea, 150 gm. of milk), 101 

Sugar 10 gm. (5 hss.), 40 



CHRONIC GASTRIC CATARRH. 203 

Half -past ten o'clock : Calories. 

Kumyss or zoolak or milk, 250 gm. (§ viii. J), 168 

Crackers, 30 gm. (one ounce), 107 

Butter, 20 gm. (5 v.), 163 

Half -past twelve o'clock: 

Two ounces of tenderloin steak or the white meat of chicken, ... 72 

Mashed potatoes, or thick rice, 100 gm. (5 hi. §), 127 

White bread, two ounces, 153 

Butter, one-half ounce, 107 

One cup of cacao, 200 gm. (3 vi. § ), 101 

Half-past three o'clock: 

The same as half-past ten, 438 

Half-past six o'clock: 

Farina, hominy, or rice boiled in milk, one plateful, 250 gm. (o viii. |) 440 

Two scrambled eggs, * 160 

Bread, two ounces 156 

Butter, one-half ounce, 107 

2^863 

The patient having been kept on this diet for a week or two, 
the diet must be gradually changed to one suitable for the 
lighter forms of chronic gastritis. Here the following rule will 
apply: The diet should correspond as nearly as possible to the 
common mode of living. In this way the distribution of the 
meals should be arranged according to the customs prevailing 
in those places in which the patients live. All foods derived 
from the vegetable kingdom should be given in large portions, 
while the quantity of meat should be somewhat limited. In 
order to permit the patient to have a greater variety in his food, 
it is best not to point out a few articles he should eat, but to 
mention only those he should avoid. Forbid meat with very 
tough fibres, meat from too old animals or too fresh meat (right 
after slaughtering), meat that contains too much fat, like pork; 
forbid sausages, lobster, salmon, chicken salad, mayonnaise, 
cucumbers, pickles, cabbage, strong alcoholic drinks like liquors. 
It must be impressed upon the patient to masticate the food 
thoroughly, to eat slowly, not to think of business during meals, 
and to .-top eating before the sensation of satiety appears. The 



204 DISEASES OF THE STOMACH. 

latter advice is only necessary in persons who are accustomed 
to high living. 

Hygienic Regimen. — Besides the diet it is of importance that 
the patient should lead a rational hygienic life. The business 
hours should not be too long, and plenty of exercise should be 
advised. Walking, driving, horseback and bicycle riding, 
rowing, are all to be highly recommended. It is, however, 
necessary to tell the patients not to overexert themselves. 
Gymnastic exercises at home, especially with an exercising 
machine, are also in place. I usually tell the patient to exercise 
in the morning for about ten minutes. A cold sponge bath on 
arising, and a thorough rubbing of the skin with a thick rough 
towel, are valuable. It is furthermore of importance to see 
that the patients live in well-ventilated rooms. A prolonged 
stay in places where there is much smoke (restaurants) should 
be prohibited. 

In many instances, the regulation of diet and hygiene will 
be sufficient to improve the patient's condition. The direct 
means, however, of accomplishing this purpose comprise the 
four following: 

1. Lavage; 2. Electricity; 3. Mineral springs; 4. Medica- 
ments. 

1. Lavage. — In most cases of chronic gastric catarrh washing 
out of the stomach will prove beneficial. The mucous form of 
gastritis is especially benefited by this means. The lavage 
should be performed in the morning in the fasting condition of 
the patient. Pure, lukewarm water should be used in this 
procedure. Occasionally a small quantity of common table 
salt may be added. The lavage should be employed every 
other day for a period of two or three weeks. It is not advis- 
able to entrust this procedure to the patient, as he is apt to 
overdo it. 

2. Electricity. — In order to stimulate the stomach, the far- 
adic current has frequently been made use of. While at first 



CHRONIC GASTRIC CATARRH. 205 

the percutaneous method of electrifying the stomach was used, 
lately the direct or intragastric mode of electrization has been 
more often employed. For percutaneous electrization a very 
large sponge electrode (18 by 12 cm.) is put over the abdomen, 
covering the entire gastric region, while the other, smaller 
electrode (diameter about 5 cm.) is held to the left of the seventh 
dorsal vertebra. 

Intragastric electrization is by far more effectual and there- 
fore preferable to the percutaneous method. Here the current 
reaches the inside of the stomach in undiminished strength, 
while in the percutaneous mode of electrization the greater 
part of the current is distributed over the skin and muscles of 
the abdominal cavity, and, if any, only a small fraction of the 
cm-rent reaches the gastric mucosa. The method of intra- 
gastric electrization has been described above (page 174). In 
chronic gastritis the faradic current should be employed. By 
means of intragastric faradization all the subjective symptoms 
frequently disappear, and if the electric treatment is adminis- 
tered over a period covering from two to three months there is 
often a lasting amelioration in the condition of the patient. 
The cases most suitable for this mode of treatment are those 
forms of chronic gastric catarrh in which not much mucus 
appears in the stomach. 

3. Mineral Springs. — There are many mineral springs, the 
waters of which have a decided beneficial influence upon the 
chronic gastric catarrh. Many patients going to these water- 
ing-places and chinking the waters at the springs either become 
improved or are entirely cured. While these waters may be 
taken with some benefit at home, still a sojourn at a watering- 
place combines many other curative factors besides the water: 
the perfect rest and absence of all cares, and the fresh and 
invigorating country air. 

The mineral springs which are most useful in this affection 
are the following: 



206 DISEASES OF THE STOMACH. 

1. Saline springs containing sodium chloride, and small or 
large amounts of carbonic acid gas: Weisbaden (Kochbrunnen 
— temperature, 69° C; sodium chloride, 0.G8 per cent.), Kissin- 
gen (Racoczi and Pandur — temperature, 10.7° C; sodium 
chloride, 0.55 per cent.), Homburg (Elisabethbrunnen — tem- 
perature, 10.6° C; sodium chloride, 0.98 per cent.), Soden 
(numerous sodium chloride [0 . 24-1 .4 per cent.] springs contain- 
ing carbonic acid gas, of different temperatures [15°-30° C.]), 
Saratoga (Congress Spring). 

2. Alkaline saline springs, containing sulphate of sodium, 
carbonate of sodium, sodium chloride, and carbonic acid gas in 
large amounts: Carlsbad (there are twelve springs, each pos- 
sessing about the same quantity of salts: Sulphate of sodium, 
0.23 per cent.; bicarbonate of sodium, 0.2 per cent.; sodium 
chloride, 0.1 per cent.; carbonic acid gas), Marienbad (Kreuz- 
brunnen and Ferdinandsbrunnen, 0.5 per cent, sulphate of 
sodium), Saratoga (Hawthorn Spring). 

In most instances the first group of springs (saline) is to be 
recommended. The second group of springs (alkaline saline) 
is to be employed in patients in whom constipation forms a 
very marked symptom. The use of these springs should, how- 
ever, not be extended over too long a period of time. Patients 
of a nervous character should not partake of these purgative 
waters. Both the saline and alkaline saline waters can be 
taken at home, if the patient is not able to go to the springs. 
It is best to have the patient drink about a tumblerful of either 
of the waters early in the morning when arising, about an hour 
before breakfast. 

4. Medicaments. — The medicaments were used to a much 
greater extent in the treatment of chronic gastric catarrh in 
olden times than nowadays. At present we have learned to 
pay more attention to diet, to hygiene, and to the mechanical 
means of treating the stomach. In some instances, however, 
the medicaments are also serviceable. Among these, hydro- 



CHRONIC GASTRIC CATARRH. 207 

chloric acid is one that is most frequently employed in this 
affection. The idea of supplementing the deficiency of gastric 
juice by tins acid, which forms its principal element, is quite 
natural. Leube 1 first introduced this medicament into the 
therapeusis of chronic gastritis and Ewald 2 likewise recommends 
it very highly. He says: "La all cases where a diminution 
or absence of hydrochloric acid has been determined, i.e., in all 
cases of chronic gastritis, it is therefore to be given preferably 
as the dilute hydrochloric acid of the pharmacopoeia in large 
quantities, and certainly in larger doses than have thus far 
been recommended." The best way to administer this medica- 
ment is to give it in the form of drops, six to twelve of the dilute 
hydrochloric acid in a glassful of water, to be taken three times 
a day half an hour after meals, not drinking the whole glassful 
of water at once, but one-third at a time at intervals of one- 
quarter of an ho m or half an hour. Ewald advocates larger 
doses than these, namely, forty to sixty drops of the dilute 
hydrochloric acid three times daily. 

Pepsin used to be, and is yet very frequently given in combi- 
nation with hydrochloric acid, the close being about half a 
gram three times daily. Most writers, however, concur in the 
absolute inefficacy of this drug, and for two reasons, viz., 
(1) in most instances even of diminished gastric secretion 
(diminished acidity) there is yet an abundant quantity of 
pepsin present; (2) most pepsins that are in the market do 
not by any means show as strong digestive properties as the 
true pepsin of the stomach. 

Formerly I was in the habit of employing hydrochloric acid 
either alone or in combination with pepsin quite frequently. 
Of late years, however, I have entirely abandoned the use of 
pep-in, and greatly restricted the administration of hydro- 

1 Leube: "Die Krankhoitcn dea fcfftgens und Darms." Ziomssen's "Hand- 
biich der spec. Patholog. und Therapie," Bd. vii., Heft 2, p. 75. 
•Ewald: I. c, p. 342. 



JOS DISEASES OF THE STOMACH. 

chloric acid. The reason for this is based upon the belief that 
the means which serve for the digestion and utilization of food 
by the organism are certainly not limited to the stomach, but 
that the principal part of this process takes place in the intes- 
tine. The artificial means of aiding digestion are certainly not 
necessary, the more so since if employed for long periods of 
time they frequently become injurious to a certain extent. 
Every organ is strengthened by activity and weakened by the 
lack of exercise. Predigested foods, or medicaments which 
contain the active principles of the gastric juice and serve to 
replace the work done by the stomach, will, in the course of 
time, have a deteriorating effect upon the gastric functions. 
The stomach will grow weaker and weaker the more artificial 
gastric juice is poured into it, and the finer and more subtle 
the nourishments that are alio ted to it. While I do not advo- 
cate the frequent use of hydrochloric acid and pepsin, I am 
strongly in favor of the administration of the so-called bitter 
medicaments (amara), condurango, quassia, gentian, kino, 
calumba, and nux vomica, which must be considered as effect- 
ive stimulants of the gastric functions. Although the physio- 
logical efficacy of these drugs has been disputed by several 
writers (Tschelzoff and Jaworski), 1 empirical experience, how- 
ever, speaks highly in their favor, and their use should certainly 
not be neglected. There is no doubt that condurango, quassia, 
and nux vomica increase the appetite, and in this way make the 
stomach fit to receive more food and thus raise the nutrition 
of the organism. I usually give fluid extract of quassia, 
calumba, or condurango in doses of twenty drops three times 
daily, or tincture of nux vomica, either alone in doses of ten 
drops three times daily, or in combination with the above 
drugs. All these medicaments must be taken about a quarter 

1 Jaworski : " Experimenteller Beitrag zur Wirkung und therapeutischen 
Anwendung der Amara und der 4 Galle." Zeitschr. f. Therapie, 1886, 
No. 23. 



CHROXIC GASTRIC CATARRH. 209 

of an hour before meals in about a tablespoonful of water or 
wine. Creosote I frequently give in the gastritis of phthisical 
patients. 

R Creosote 5.0 

Compound tincture of gentian, 10.0 

S. Eight drops in half a glassful of milk three times daily, half an hour 
after meals. 

Orexin may also be given for the same purpose: 

R. Orexin. basic . 0.2 (gr. iijss.) 

D. in wafers t. d., Xo. 15. Sig. One wafer in a cup of bouillon half an 
hour before meals twice daily. 

Chronic gastric catarrh is frequently combined with consti- 
pation, and it will be necessary to speak about the manage- 
ment of this complication. As a rule, I would say that the 
less medicaments used to combat this affection the better. 
The means available for this trouble are: You must tell the 
patient to go to the water-closet in the morning at a certain 
hour, to avoid much straining, and not to bother about the 
bowels any more during the whole day, even if there were no 
movement, and not to go to the water-closet unless there be 
a strong inclination for it until the following morning. Fre- 
quently this alone is sufficient to secure regularity of the bowels 
after a while. 

The diet can also be arranged in such a manner as to facili- 
tate movements of the bowels. All foods which contain a 
large percentage of cellulose (undigested matter) increase the 
quantity of faeces, and thereby effect a stronger peristalsis of 
the large bowel. All kinds of green vegetables (spinach, aspara- 
gus, green peas) and rye bread are therefore very suitable. 
Many organic acids possess the property of increasing intes- 
tinal peri>tal-i<. Almost all kinds of fruits contain a certain 
quantity of these organic acids, and act like mild aperients. 
The use of cooked pears, stewed or baked apples, stewed prunes, 
is in many instances effective. Ewald recommends a mixture 
H 



210 DISEASES OF THE STOMACH. 

of two parts of prunes to one part of dried figs. The taste is 
agreeable and the cathartic action mild. The custom of eating 
an orange in the morning for its laxative effect is well known. 
To these dietary remedies we may also add the use of a glassful of 
either very cold or warm water, or of a glass of milk on arising, 
in the fasting condition. There are many persons in whom 
one of these latter means produces a good movement of the 
bowels. 

In cases where the above dietary remedies do not suffice, 
the administration of a mild cathartic is not out of place. 
Rhubarb and cascara sagrada are chiefly in use. The former 
is given either in substance or in the form of a tincture, fifteen 
to thirty drops; the latter in the form of the fluidextract, 
fifteen to twenty-five drops twice daily. Aloes and podophyllin 
should be used only in the severer forms of constipation. I 
frequently give the following pills: 



1$ Podophyllin, 0.3 (gr. v.) 

Extract of nux vomica, 

Extract of Calabar bean, aa 0.5 (gr. viij.) 

M. f. cum extr. gentian, et pulv. liq. q. s. pil. No. 30. S. One pill twice 
a day. 



The so-called Hamburg tea is also very efficacious. 

Phenolphthalein-agar (3 parts phenolphthalein imbibed in 
100 parts of agar), one teaspoonful twice daily, after break- 
fast and supper, in some water, is likewise greatly beneficial. 

All of these remedies should not be used for too long a time, 
and the patients should always accustom themselves to get 
along with fewer of these remedies, and ultimately without 
them. In cases in which there is atony (weakness) of the 
large intestine, the use of enemata is indicated. One quart 
of lukewarm water with a teaspoonful of salt is injected into 
the rectum by means of a fountain syringe provided with a soft>- 
rubber tube. These injections should be made once a day, 



CHRONIC GASTRIC CATARRH. 211 

always at the same hour, and continued for about two weeks. 
The use of glycerin suppositories, or of a small quantity of 
glycerin in water (one teaspoonful to four or five tablespoonfuls 
of water) injected into the rectum, will be required only occa- 
sionally. 



CHAPTER VI. 

ORGANIC DISEASES WITH CONSTANT 
LESIONS.— Continued. 

Ulcer of the Stomach. 

Synonyms. — Ulcus pepticum seu roclens; ulcus ventriculi 
rotundum; ulcus simplex; ulcus ventriculi chronicum per- 
forans. 

Definition. — Gastric ulcer is a disease characterized by a 
more or less deep destruction of the mucous membrane of the 
stomach, exhibiting no tendency to healing, and attended 
with symptoms of pain, vomiting, and hemorrhage. Cruveil- 
hier 1 in 1829 was the first to describe this affection. 

Etiology. — The etiology of ulcer of the stomach has not yet 
been definitely elucidated. Age and sex seem to play a promi- 
nent part in its development. It is of quite frequent occur- 
rence. According to Brinton 2 ulcer of the stomach is found 
(either open or cicatrized) in about five per cent, of persons 
dying from all causes. He further states that ulcer is more 
frequent in the female than in the male sex, the proportion 
being nearly as two to one. As regards age, the liability of 
an individual to become the subject of gastric ulcer gradually 
rises from what is nearly zero at the age of ten to a high rate, 
which it maintains through the period of middle life at the end 
of which it again ascends to reach its maximum at the extreme 
age of ninety. Ulcer of the stomach is especially, though not 
exclusively, a disease of middle and advanced life. According 

1 Cruveilhier: "Anatomie pathologique, " 1829-1835, Livraison x. 

2 W. Brinton: I. c. 

212 



ULCER OF THE STOMACH. 213 

to Ewald, 1 ulcer of the stomach occurs most frequently between 
the twentieth and fortieth years, while its mortality is highest 
between the ages of forty and sixty. 

The frequency of ulcer of the stomach seems to vary in dif- 
ferent localities. Thus Berthold 2 gives the percentage of ulcer 
of the stomach for Berlin as 2.7 per cent.; Nolte for Munich 
as 1.23; Gries for Kiel as 8.3; Stark for Copenhagen as 13. 
Von Sohlern 3 has lately called attention to the fact that the 
Roen Mountains and the Bavarian Alps (Germany) and the 
greater part of Russia are nearly exempt from gastric ulcer. 
He further stated that the inhabitants of these territories 
exist almost exclusively on a vegetable diet. As such a diet 
i^ very rich in potassium salts (containing nearly one-third 
more of this salt than a mixed diet), and as the red blood cells 
are to be regarded as the chief carriers of potassium, von 
Sohlern claims that this increased amount of potassium repre- 
sents the cause of the relative immunity of the above-mentioned 
inhabitants from ulcer of the stomach. On the basis of this 
theory, von Sohlern recommends the administration of potas- 
sium salts and of foods rich in vegetable matter as a prophy- 
lactic measure against ulcer. His theory, however, lacks the 
support of examination of the blood which alone could prove 
the correctness of the above statement. 

It has been furthermore asserted, especially by the English 
writers, that the frequency of gastric ulcer is greatly dependent 
on the various callings of life. Thus every one is familiar 
with the belief that cooks are especially subject to this malady. 
Shoemakers, porcelain makers, etc., are also mentioned as fre- 
quent sufferers from ulcer. These statements, however, are 
not based on correct data. Ewald, for instance, is of the 



: C. A. Ewald: I. c, p. 234. 

1 Cited from Ewald: "Diseases of the Stomach," p. 233. 
1 Von Sohlern: " Der Einfiuss der Ernahrung auf die Entstehung des 
Magengeschwiirs." Berl. klin. Wochenschr., 1889, No. 14. 



214 DISEASES OF THE STOMACH. 

opinion that even in cooks gastric ulcer is not more common 
than in other people. 

Numerous writers have endeavored to study the etiology of 
ulcer by the way of experiments on animals. They have 
produced lesions of the gastric mucosa by cutting out a piece 
of the inner layer or by subjecting it to different caustic chem- 
icals, but the investigations of Griffini and Vassale 1 showed 
that the mucous membrane of the stomach of such animals 
quickly replaces the defect experimentally produced and that 
after a short while the lesion is entirely healed. Thus these 
acute defects of the mucous membrane cannot properly be 
called ulcers, for they show no tendency to spread. 

From these experiments it has been concluded that in the 
production of the gastric ulcer there must be not only a lesion 
of the mucosa, but also some anomaly in the condition of the 
blood. Quincke and Daettvyler 2 made animals anaemic by 
venesection and produced lesions in the gastric mucosa. In 
these instances the defect did not heal and a condition similar 
to a real ulcer was established. In some of the animals even 
perforation of the ulcer took place. Koch and Ewald 3 produced 
gastric hemorrhages in animals by section of the spinal cord. 
By introducing one-half-per-cent. solution of hydrochloric acid 
into their stomachs deep ulcers arose. Silbermann 4 introduced 
substances into the circulation which disintegrated the blood 
corpuscles and produced hsemoglobinsemia. Here also the 
artificial defect of the gastric mucosa healed very tardily, and 
presented a similar aspect to a real ulcer. Turck 5 has suc- 



1 Griffini und Vassale: " Beitrage zur patholog. Anat." von Ziegler und 
Nauwerck, Bd. 3, Heft 5, p. 425. 

2 Quincke und Deattvyler: Correspondenzbl. f. Schweizer Aerzte, 1875, 
p. 101. 

3 C. A. Ewald: " Klinik der Verdauungskrankheiten," 1. Theil, 3. 
Aufl., p. 122. 

'Silbermann: Deutsche med. Wochenschr., 1886, No. 29. 
6 F, B. Turck: Journal American Med. Assoc, June 9th, 1906. 



ULCER OF THE STOMACH. 215 

ceeded in producing typical ulcers of the stomach in animals 
by feeding them for a long period with pure cultures of bacter- 
ium coli commune. 

There is no doubt that the above experiences gained by 
experiments on animals apply also to the human being. Acute 
lesions of the gastric mucosa in man very frequently occur and 
heal very rapidly without any ill effects. Clinically we know 
of cases in which a trauma in the gastric region produced 
hemorrhage by causing a tear in the gastric mucosa. In a few 
days, however, the patients recovered without presenting any 
gastric symptoms whatever at a subsequent period. Old 
English literature contains several reports of cases in which 
persons had swallowed knives which had passed the whole 
digestive tract without presenting any palpable symptoms. 
One of the most striking instances is that reported by Dr. 
Marcet 1 and mentioned by Ewald. "In the year 1799 an 
American sailor saw a juggler in Havre perform the trick of 
knife swallowing. Returning to his vessel somewhat intoxi- 
cated he was foolhardy enough to try to swallow his open 
pocket knife, and succeeding in this, he ate three more. Three 
passed off in the stool during the next few days, but one dis- 
appeared forever. One evening, six years later, he again 
swallowed portions of six knives, but this time not without 
unpleasant though very transient results, on account of which 
he was admitted to a hospital. He did this frequently till he 
had swallowed about thirty-five knives. Finally he was taken 
seriously ill and he died in Guy's Hospital in London in 1809. 
In the stomach some thirty pieces of blades, in parts markedly 
corroded, together with handles, were found; two blades in 
the colon and rectum which were placed transversely and had 
perforated the intestinal wall (and that without causing 
peritonitis!), but no recent or old ulcers of the stomach or 
any remains of them." In this as in other instances undoubt- 

1 Marcet: Medico-Chirurgical Transactions, vol. xii., p. 72. 



216 DISEASES OF THE STOMACH. 

edly the gastric wall had suffered considerable injury but 
quickly regained its normal state. 

A similar instance of a grave lesion of the gastric mucosa 
without any ill effects I had the opportunity to witness myself, 
and it might be worth while briefly to describe it. 

A boy of eleven years, suffering from epilepsy, during one of 
his attacks fell from a window on the first floor of the house into 
the yard, striking the stone pavement with his abdomen. He 
was found unconscious and brought up into his room, where he 
remained in this condition for about an hour. Upon thorough 
examination no traumatic lesions of the skull could be dis- 
covered; his nose did not bleed, nor was any blood found in his 
mouth. About two hours after his fall he suddenly vomited 
over a pint of fresh blood partly mixed with food. Six hours 
afterward about the same quantity of blood was again brought 
up. On palpation there was no pain in the gastric region. 
The boy was kept quiet for a few days and quickly recovered. 
Even during his stay in bed he never complained of pain. 
Afterward he could eat everything and remained entirely free 
from gastric symptoms. 

Analogous to the above experiments on animals which had 
been rendered anaemic, we also find gastric ulcer quite fre- 
quently in chlorotic individuals, and it may be readily imagined 
that many lesions of the gastric mucosa which would otherwise 
remain without ill effects are prevented from healing by the 
depreciated condition of the blood and become converted into 
ulcers. It is, however, impossible to say that this theory 
would apply to all cases of ulcer of the stomach, for very often 
we find this affection in people who are a picture of health, and 
whose blood condition is apparently without any anomalies. 

Other Theories as to the Origin of Gastric Ulcer. — As is well 
known, erosions of the gastric mucosa are found in chronic 
gastritis and in other diseases complicated with disturbances 



ULCER OF THE STOMACH. 217 

of circulation. The origin of erosions is explained by Harttung 1 
in the following way: The contraction of the muscularis of 
the stomach produces an arrest of the circulation in the rugae 
with intense congestion in the veins and capillaries, which in 
turn gives rise to hemorrhages into the mucous membrane. 
Hemorrhagic infiltration of the mucous membrane arises, in 
consequence of which the latter receives little or no fresh cir- 
culating blood, and very soon succumbs to the digestive effects 
of the gastric juice. In this way the decay and the destruction 
of the tissue and the hemorrhagic erosion are produced. These 
erosions are superficial defects of the gastric mucosa, extending 
as a rule not deeper than half its thickness. Rokitansky, 2 and 
subsequently Rindfleisch 3 and Key, 4 established the theory 
that the ulcer arises from the further development of an erosion 
(hemorrhagic erosion). 

The view, however, that there is a difference in degree but 
not in type between erosion and ulcer of the stomach is not 
correct. Langerhans 5 based his opposition to this theory on 
his experience gained in autopsies. I 6 have shown that the 
diagnosis "erosions of the stomach" can be made clinically, 
and stated that in none of the cases observed by me an ulcer 
developed. Virchow 7 first expounded the view that the ulcera- 
tive process may result from plugging up of the nutrient artery 
of a certain part of the mucosa either by an embolus or by a 
thrombus, and that the infarct thus produced is destroyed by 
the gastric juice. In this way a circumscribed defect arises. 



1 O. Harttung: "Ueber Faltenblutungen und hamorrhagische Ero- 
sionen." Deutsche med. Wochenschr., 1890, Xo. 38, p. 847. 

2 Rokitansky: "Lehrbuch der patholog. Anatomic" 

3 Rindfleisch : u Lehrbuch der patholog. Anatomie." 
'Axel Key: Gurlt-Virchow's Jahresb., 1871. 

Langerhans: Virchow \s Arch., Bd. 124, p. 373. 
•Max Einhorn: Medical Record, June 23d, 1804. 
7 R. Virchow: Virchow's Archiv, Bd. v.. p. 363. 



218 DISEASES OF THE STOMACH. 

Although this view has been greatly supported by Panum's 1 
experiments, who succeeded in producing emboli in the gastric 
arteries and ulcers in consequence thereof, it is, however, still 
undecided whether this etiological factor comes into play in all 
cases of gastric ulcer; for very often the evidence of an embo- 
lized or thrombosed artery in the neighborhood of the ulcer is 
missing. Instead of the older theory that the diminished alka- 
linity of the blood is the cause of the ulcer (Pavy 2 ), the newer 
one has been generally accepted: that the hyperacid gastric 
juice is the most important etiological factor in the production 
of ulcer. Although this theory had already been expressed by 
Wilson Fox 3 and others of the older writers, the credit of having 
placed it on a firmer basis belongs to the more recent investi- 
gators, Riegel, 4 Jaworski and Korczynski, 5 Ewald 6 and Charles 
G. -Stockton. 7 It has been found by these authors that hyper- 
acidity of the gastric juice is, if not of constant, at any rate of 
very frequent occurrence in gastric ulcer. Futhermore, it was 
ascertained that those conditions in which gastric ulcer is very 
frequently found (as, for instance, chlorosis, anaemia, amen- 
orrhcea) are also associated with a hyperacid gastric juice. 
From my own experience I would certainly say that hyper- 
acidity is very often met with in gastric ulcer. There are, 
however, exceptions to this rule, and twice I had the oppor- 
tunity of observing gastric ulcer in cases in which there 
was an entire absence of gastric juice (achylia gastrica). One 



1 Panum: " Experimented Beitrage zur Lehre von der Embolie." Vir- 
chow's Archiv, Bd. 25, 1862. 

2 Pavy: "On Gastric Erosion." Guy's Hospital Reports, vol. xiv., 1868. 

3 Wilson Fox: "The Diseases of the Stomach," 1872, p. 146. 

4 F. Riegel: Zeitschr. f. klin. Med., Bd. xii., p. 434, and Deutsche med. 
Wochenschr., 1886, No. 52. 

5 Jaworski und Korczynski: Deutsche med. Wochenschr., 1886, Nos. 
47-49. 

"C. A. Ewald:?. c, p. 229. 

7 Charles G. Stockton: "The Etiology of Gastric Ulcer." The Medical 
News, January 14th, 1893. 



ULCER OF THE STOMACH. 219 

of these cases did not present any symptoms indicative of an 
ulcer, the latter had been found accidentally in performing an 
exploratory laparotomy on the patient. 
This case is as follows: 

G. M , 56 years old, has been complaining for the last three 

years of attacks of dizziness, extreme anorexia, and occasional 
vomiting. For weeks after such an attack patient could not walk 
well on account of a giddy feeling which he often experienced. 
Bowels were rather constipated. The physical examination of 
the patient did not reveal anything abnormal, except an anaemic 
state which found expression in a pale color of the mucous mem- 
brane of the lips, eyelids, and the palate. A splashing sound 
could be easily produced in the gastric region down to the navel. 
The urine did not contain sugar or albumin. The gastric con- 
tents were frequently examined in the course of a whole year 
with always about the same result : HC1 = 0, acidity between 2 and 
4, no rennet, no pepsin, no biuret test. Patient improved on a 
richly vegetable diet and gained some pounds in weight. Sud- 
denly, however, he was overcome with an attack of jaundice, 
accompanied with severe pains and fever. Since that time the 
pains were more constant than previously, and remained so even 
after the jaundice had entirely disappeared. The patient's 
condition turning from bad to worse, a consultation was held with 
Dra. A. Rose and F. Lange, and an exploratory laparotomy was 
decided upon, gall-stones apparently being at the bottom of the 
trouble. The operation was performed by Dr. F. Lange in my 
presence. Xo gall-stones were found. The liver appeared 
normal. On examining the stomach, however, a small spot (the 
size of a twenty-five-cent piece), situated in the anterior wall 
about three inches distant from the lesser curvature as well as 
from the pylorus, was found necrotized and on the border of 
perforation. This piece was excised and a typical ulcer found. 
The stomach was sewn together. The patient got along nicely 
for the first week after the operation when pneumonia developed, 
which caused a fatal issue. 

Ewald, though a fervent advocate of the last theory, pre- 
supposes a predisposition of certain persons to this affection in 



220 



DISEASES OF THE STOMACH. 



order to explain the many instances where the theory of 
hyperacidity would not apply. 

The probability is that gastric ulcer is not always produced 
by one and the same factor, and all the above theories may 
apply more or less in different instances. 

Morbid Anatomy. — The peptic ulcer is found only in those 
regions which are exposed to the gastric juice. Aside from the 




Fig. 71. — Ulcer of the Stomach near the Pylorus, the latter being stenosed. a, Stomach, 
b, pylorus; c, ulcer. (From writer's observations.) 



stomach it is met with in the lowest part of the oesophagus 
and the upper part of the duodenum. The typical gastric 
ulcer has a round or oval (sometimes oblong) appearance. It 
extends to various depths of the gastric wall, the upper part 
being the larger, the inferior smaller, presenting in this way 
more or less the shape of a funnel. 

A typical ulcer looks as if it were cut out with a punch. In 



ULCER OF THE STOMACH. 



221 



most instances the base of the ulcer is smooth, occasionally it 
is covered with tenacious greenish or brownish mucus. In 




Fig. 72. — The same specimen drawn in smaller proportions, in order to show the surround- 
ings of the ulcer. 




Fig. 73. — Showing the entire cross-section of an excised ulcer as it appears under the 
lens. The concave line forms the interior, the convex the outside of the stomach. The 
middle portion is deprived of the glandular layer; to the left a few glands are left. X4. 
(From writer's observation.) 



microscopic sections through the margins of a recent ulcer, the 



.)■)•) 



DISEASES OF THE STOMACH. 



ducts of the glands appear as though cut off toward the base 
of the ulcer. They are eaten away or digested up to the point 
where the tissues offer sufficient resistance to the digestive 
power of the gastric juice. In older ulcers, however, a reactive 



^S&ii 



mvm 






&M^-:'¥ 











£-.\ C'-*.> -V- 



Fig. 74. — The left corner of Fig. 73, as seen under the microscope with low power. 
Glands are visible to the left of the drawing, the rest consisting principally of a proliferation 
of cells and connective-tissue formation. 

inflammation sets in at the periphery, leading to the formation 
of a callous margin. The latter may become very much indu- 
rated, and may give on palpation the impression of a tumor, 
the more so if the thickened portion be situated near the 
pylorus. Aside from the inflammation of the narrow margin 
of the ulcer, the mucous membrane of the whole stomach 



ULCER OF THE STOMACH. 



223 



remains in most instances normal, this being according to 
Rosenheim 1 a principal characteristic of ulcer, which unlike 
cancer consists in a well-circumscribed necrotic process having 
no further influence upon the gastric mucosa. 

The size of the ulcer is rarely much smaller than a five-cent 
piece or larger than a twenty-five-cent piece, although no 

ft 




Fig. 75. — Showing One Spot of a Proliferation of Cells lying in the Centre of the Specimen 
(Fig. 73) resembling very much a spindle-cell sarcoma. Highly magnified. 

precise limits can be given. Thus an ulcer not larger than a 
pea may exhibit all the characters of this lesion, while con- 
versely an ulcer may gradually attain a diameter of five or 



1 Th. Rosenheim: "Pathologie und Therapie der Krankheiten der Spei- 
serohre und des Magens," Wien und Leipzig, 1891, p. 161, 



224 DISEASES OF THE STOMACH. 

six inches. Debovc and Remond 1 mention a case of gastric 
ulcer of the size of the palm of the hand. 

Situation of the Ulcer. — According to Brinton, 2 gastric ulcer 
occupies the various parts of the stomach in the following fre- 
quency: In 43 cases out of 100 the posterior surface, in 27 
cases the lesser curvature, in 16 cases the pyloric extremity, 
in 6 cases both the anterior and posterior surfaces, often at 
opposite places; in 4 cases the anterior surface only, in 2 cases 
its greater curvature, in 2 cases the cardiac pouch. 

Thus about 86 ulcers in every 100 occupy the posterior 
surface, the lesser curvature, the pyloric sac, parts of the 
stomach which together form a segment of less than half of 
the total superficies of the organ. 

Hence we may estimate that any part of this continued (but 
irregular) segment of the stomach is on an average about five 
times more liable to the lesion than the remaining segment 
formed by the cardiac sac, the anterior surface, and the greater 
curvature. 

Nolte's 3 figures do not harmonize with those just given. 
Nolte presents the following scale of frequency: At the 
greater curvature, 22; at the pylorous, 13; at the anterior 
wall, 3; at the posterior wall, 2; at the cardia, 1. 

Welch's statistics harmonize more with Brinton's figures. 
Out of 793 cases collected by this eminent American writer, 
288 ulcers were situated in the lesser curvature, 235 on the 
posterior wall, 95 at the plyorus, 96 at the anterior wall, 50 
at the cardia, 29 at the fundus, 27 on the greater curvature. 4 

Number. — As regards the number of ulcers, according to 
Brinton, 2 or more are present in 1 out of every 5 cases, or 
about 21 per cent. Out of 97 such plural cases (corre- 



1 Debove et Remond: "Traite des Maladies de l'Estomac," Paris, p. 255. 

2 \\ . Brinton : I. c. 

3 \<>lte: SeeEwald, I. c, 239. 

4 Welch: Cited from Osier's "Practice of Medicine," p. 369. 



ULCER OF THE STOMACH 225 

sponding to 463 instances of nicer), in 57 there were 2 ulcers, 
in 16, 3, and of the remaining 24 in which "several" ulcers 
were present, 3 cases offered 4 and 2 cases 5 ulcers each; while 
in 4 there is reason to suppose even tins number was exceeded. 

Further Progress of the Ulcer. — 1. Cicatrization. The ulcer, 
as a rule, does not heal with restitution of the normal muscle 
membrane, but leaves behind a fibrous, centrally depressed 
scar, which has a tendency to contract. If such a scar be 
situated at the pylorus, its contraction may produce stricture 
of this outlet. If the ulcer had a girdle-like shape, constriction 
of the viscus may occur, and give it the form of an hour- 
glass. 

2. Progressive Necrosis and Corrosion. If cicatrization 
does not occur, the necrotic process may continue for a long 
period and may cause the following complications: 

(a) Corrosion of vessels. Vessels of larger or smaller calibre 
may become opened and give rise to hemorrhage, or if a very 
large vessel is affected even to fatal bleeding. Among those 
more frequently involved are the gastric, splenic, and pan- 
creatic arteries. 

(b) Adhesions to neighboring organs and perforations. As 
soon as necrosis extends to the serosa, it leads either to a 
reactive inflammation with adhesions to surrounding organs 
and extension of the process to them, or where circumstances 
do not permit such adhesions, to a direct perforation into the 
abdominal cavity. After the adhesions have formed, a per- 
foration may yet take place into a neighboring cavity. Thus 
perforation into the pleural or pericardial cavities occurs, or 
sometimes a fistula is formed between the stomach and duode- 
num or colon. According to the site of the ulcer, any of the 
neighboring organs, liver, gall bladder, pancreas, spleen, dia- 
phragm, heart, lungs, etc., may become subject to these adhe- 
sions. Perforations of the anterior wall of the stomach are 
most dangerous on account of the greater mobility of this part 

15 



226 DISEASES OF THE STOMACH. 

of the organ and the consequent lack of adhesive inflammation. 
These, as a rule, terminate fatally. 

Symptomatology. — A typical case of gastric ulcer is ushered 
in by disturbances of the gastric digestion. At the beginning 
there is merely a feeling of uneasiness and pain in the epigastric 
region; but these are soon followed by nausea and regurgita- 
tion or vomiting. These symptoms may undergo no change 
for a long period; at times, however, they become more severe 
in character. The pains especially take on a more aggravated 
form, and many patients are afraid to eat on account of them. 
Very often a hemorrhage from the stomach occurs, producing 
an increase of the ansemia and cachexia which already ' exist 
in consequence of subnutrition. If the disease takes a pro- 
gressive course, it is liable to end lethally by perforation 
hemorrhage, or by inanition. In most instances, however, 
the course of the disease is cut short either by a spontaneous 
cicatrization of the ulcer, or by the same process being brought 
about by our rational means of treatment. The symptoms- 
then gradually disappear, and recovery takes place. In many 
instances the symptoms of the disease reappear after the lapse 
of various periods of time (one or several years). It is then 
quite difficult to decide whether we have to deal in these 
instances with the formation of new ulcers, or a breaking down 
of the cicatrix of the old lesion. As the above-mentioned 
symptoms of ulcer are met with likewise in many other 
disturbances of the stomach, and inasmuch as each of 
them has its specific character in the different lesions, it 
will be best to analyze each of the symptoms of gastric ulcer 
separately. 

1. Pain is the most frequent and characteristic of all the 
symptoms. In the earlier stage of the disease there is a mere 
feeling of weight or tightness in the epigastric region. Some- 
times the patient has the impression as though the food experi- 
enced a stoppage there. From such a dull, continuous feeling 



ULCER OF THE STOMACH. 227 

the pain gradually augments into a burning sensation and at 
last into a gnawing pain. 

In the majority of cases the pain comes on from two to ten 
minutes after deglutition of food and remains during the period 
of gastric digestion, at the close of which it gradually subsides 
and disappears. There are, however, exceptions to this rule, 
and we find cases of typical gastric ulcer where the pains ap- 
pear half an hour or an hour or two and three hours after 
meals. Different kinds of food have a marked influence upon 
the pain. Coarse substances and many undigestible foods in- 
crease the pain, whereas a liquid diet, especially milk, may 
fail to bring on the pain. The quantity of food is also of im- 
port, a large meal causing more pain than a small one. 

The situation of the pain corresponds, as a rule, to the centre 
of the epigastrium, or to the median line of the abdomen imme- 
diately before the free extremity of the ensiform process. The 
portion of the epigastric region to which the pain is referred 
forms a circular area of rarely more than two inches diameter, 
sometimes a mere spot of less than half this size. There are, 
however, exceptions to this rule, and a spot of pain may be 
situated a little more to the right or to the left or also farther 
down than the above-described spot. Occasionally the pain 
-ociated with a feeling of violent pulsation or throbbing 
in the epigastric region. At times this sensation is felt inde- 
pendently of the paroxysm of pain. 

The dorsal pain, first described by Cruveilhier, is also an 
important symptom. It generally appears later (a few weeks 
or months) than the epigastric pain, and is then almost as con- 
stant and characteristic as the epigastric pain. This pain is 
gnawing in character and situated, as a rule, to the left of the 
spine corresponding to the eighth or ninth dorsal vertebra, 
and extending occasionally to that of the first or second lumbar 
vertebra. Like the epigastric pain, it has a fixed seat, gener- 
ally remaining near the spot of its first appearance during the 



228 DISEASES OF THE STOMACH. 

whole 4 progress of the disease, although it also shows lateral 
as well as vertical deviation from its ordinary situation. Its 
worst attacks generally alternate with those of the epigastric 
pain. 

The epigastric pain is increased on pressure. Even slight 
pressure with the finger upon the epigastric region below the 
ensiform process produces intense pain. This is the most 
important point characteristic of gastric ulcer. To test the 
sensitiveness to pressure by means of Boas' algesimeter, or to 
exert considerable pressure with, the fingers, is not advisable. 
I perfectly agree with Brinton, 1 who says in reference to the 
latter point: "It is not altogether superfluous to add another 
caution with respect to the above test (pressure): not only 
must it be applied with great care and delicacy in the first 
examination of a supposed case of gastric ulcer, but, as a rule, 
we can scarcely be too reluctant to repeat it, even to verify 
a presumed amendment. At any rate, its effects are some- 
times so injurious that it is necessary strictly to prohibit the 
patient from all manipulations of the epigastric region, as well 
as from all pressure produced by dress (such as stays in the 
female) or work (as is the case with shoemakers)." 

The character of the pain, of becoming increased on pressure, 
is, however, not always present, and we find patients with 
gastric ulcer in whom the pain is rather subdued by pressure. 

2. Vomiting. — Vomiting in gastric ulcer occurs in nearly the 
same proportion of cases as pain. As a rule, it is absent during 
the first period of the disease, and appears somewhat later than 
the pain. Sometimes, however, both these symptoms occur 
simultaneously. The vomiting, most frequently met with in 
cases of ulcer, appears an hour or two after meals, at the time 
w r hen the pain has reached its acme. As a rule, the vomiting re- 
lieves the pain. Sometimes the vomiting occurs less frequently, 
for instance once a day or still more seldom. The vomited 

1 W. Brinton: I. c. 



ULCER OF THE STOMACH. 229 

matter ordinarily consists of a watery fluid mixed with particles 
of food. Occasionally, however, the latter are absent and the 
ejected matter then consists, as a rule, of clear gastric juice 
which, in many cases of ulcer, is secreted in too abundant a 
quantity. In such instances the vomiting may occur inde- 
pendently of the meals, and thus may take place either in the 
middle of the night or early in the morning on arising. 

There are also cases in wliich vomiting takes place very soon 
after meals, or where, instead of the vomiting, there is regurgi- 
tation of food. The regurgitation may also occur two to three 
hours after a meal (the fluid brought up consisting of very acid 
gastric chyme or juice) and is very often accompanied by 
pyrosis. Again there are cases in wliich instead of the vomiting 
we have spells of nausea. Vomiting of very large quantities of 
chyme, although met with in gastric ulcer, is most character- 
istic of cases of ulcer complicated with stenosis of the pylorus, 
and will be discussed later on when dealing with that affection. 

3. Hemorrhage. — Hemorrhage is a symptom of the greatest 
importance in gastric ulcer. Since the process of ulceration 
implies a solution of continuity in the coats of the vessels of 
the stomach, there is nothing more natural than an effusion 
of blood. As a rule, however, the opening of the vessels is 
very soon obliterated by the formation of a coagulum. For 
this reason hemorrhages occurring from the very small vessels 
are not of much import, and pass unnoticed by the physician 
or the patient. It is only when a larger vessel is corroded and a 
considerable quantity of blood enters the stomach that grave 
symptoms appear. In a typical case of such a hemorrhage 
the patient experiences a sensation of fulness soon after a meal, 
combined with anxiety. Some time afterward he feels 
nauseated, restless. Suddenly vomiting of a large quantity of 
blood occurs, having either a clear red, brownish, or black color, 
possibly mixed with food (haematemesis). The patient, as a 
rule, feels faint, his face becomes pale, his extremities grow 



230 DISEASES OF THE STOMACH. 

more or less cold, and if hemorrhage goes on uninterruptedly, 
death is likely to occur in consequence of the profuse loss of 
blood. Under such circumstances the patient soon becomes 
unconscious, convulsions supervene, and life is gradually 
extinguished. If hemorrhage of a large vessel has taken place, 
it may even happen that the patient dies before any vomiting 
has occurred. In such instances the cause of death, if there 
have been no previous symptoms of ulcer, usually remains 
unknown until the autopsy, when the stomach may be found 
filled with liquid or coagulated blood. In most cases, however, 
gastric hemorrhage is not lethal. The blood, instead of being 
vomited, may pass into the intestines, and be evacuated with 
the stools, which then assume a blackish, tarry color (melaBiia). 
Very often both hsematemesis and melsena take place. 

Blood vomiting (haBmatemesis), if present, is the most 
certain sign of ulcer, and its occurrence alone is sufficient to 
warrant a positive diagnosis of this affection. In almost one- 
third of his cases of ulcer, Anderson 1 found this symptom 
present. There is no doubt that hemorrhages in gastric ulcer 
appear more frequently than we are able to recognize their 
existence. Very often in small hemorrhages the blood will pass 
through the digestive canal unnoticed, the reason being that 
small quantities of blood mixed with alimentary residues may 
be changed in such a way as to be unrecognizable. Even if 
blood be present in the stools in larger amounts, it will some- 
times pass unnoticed because the patient does not pay atten- 
tion to their color, especially nowadays when every one goes 
to the water-closet, and is not in the habit of inspecting his 
passages. Not long ago I had the opportunity twice of detect- 
ing blood in the stomach of patients who apparently never had 
any hemorrhages. In one of them, at the examination with 
the tube one hour after the test breakfast, I obtained quite a 
quantity of blood having a black coffee-ground color (under 

1 Anderson: British Medical Journal, May 10th, 1890. 



ULCER OF THE STOMACH. 231 

the microscope red blood corpuscles were present). The second 
patient was a lady presenting symptoms of gastric ulcer. 
While in the clinic, I noticed that she looked unusually pale; 
she also complained of feeling somewhat faint. As she had 
partaken of a test breakfast, I administered the stomach 
bucket, winch came up filled with a fluid of coffee-ground 
color, also containing red blood corpuscles. Frequently even 
if blood is not visibly present, there may be "occult blood," a 
fact which was first demonstrated by. Boas. The blood may 
be found in the gastric contents or in the faeces by Weber's 
guaiac or Klunge's aloin or the benzidin test. 

-i. Appetite. — Although patients with gastric ulcer partake 
of very small quantities of food, the appetite per se is by no 
means decreased. It is merely on account of the pains that 
the patients are afraid to eat, and avoid substantial meals. 
Some complain of being constantly hungry, but unable to 
satisfy their appetite, on account of the distress following the 
ingestion of food. This fear of taking food is sometimes exag- 
gerated, and the patients get into the habit of partaking of so 
little that the danger resulting from this source is certainly far 
greater than that from the original disease. 

5. Constipation. — As a rule, most cases of gastric ulcer are 
accompanied by constipation. Leube 1 explains this fact in 
the following manner: He assumes that the peristalsis of the 
stomach is impaired in gastric ulcer. As there is a reflex con- 
nection between the peristalsis of the stomach and that of the 
small intestine, the latter will also be retarded, and in this way 
the constipation would be explained. Leube's theory of the 
presence of retarded muscular action in gastric ulcer seems to 
be supported by several results which I have obtained with the 
gastrograph in a few cases of gastric ulcer, in which the motion 
of the stomach appeared to be materially lessened. My obser- 

1 Leube: I. c. 



232 DISEASES OF THE STOMACH. 

\ations in this respect, are yet too few to fully sustain this 
theory. 

G. Amenorrhea. — Amenorrhoea is quite frequently met with 
in women suffering from gastric ulcer. It appears, however, 
that this symptom is merely the consequence of the anaemic 
condition of these patients. Sometimes gastric hemorrhages 
vicariously appear instead of the monthly periods. 

7. Cachexia. — Although we sometimes meet with robust, 
healthy persons suffering from gastric ulcer, this is not the rule, 
and most frequently patients suffering from this trouble present 
an appearance which would suggest to an observant physician 
even at a distance the nature of the ailment. In connection 
with the extreme cachexia, the sharp lines which severe and 
frequent pains, together with partial starvation, have graven 
on the patient's face afford almost a characteristic sign of 
gastric ulcer. The cachexia in gastric ulcer, although at first 
not well marked, may after a time increase to such an extent 
that the patient is reduced to a mere skeleton, and emaciation 
of this kind is very seldom met with in gastric cancer. 

Condition of the Gastric Contents. — Riegel, and later Jaworski 
and Glusinsky, first signalized the fact that hyperacidity is a 
concomitant factor of gastric ulcer. Although this is not 
always the case, as we have mentioned above, the fact remains 
true that most of the cases of gastric ulcer are characterized by 
a hyperacid juice. The acidity may reach as high a figure as 
130 or even 160 (about three or four times the acidity of normal 
gastric juice). This high figure, 160, 1 had the opportunity to 
observe lately in a case of gastric ulcer near the pylorus com- 
bined with stenosis of the latter. The patient had been oper- 
ated upon, and the diagnosis verified in vivo in this manner. 
Kaufmann 1 asserts that mucus is absent in gastric ulcer. In 
cases in which there is vomiting the ejected matter should be 

1 J. Kaufmann: American Journal of the Medical Sciences, February, 
1908. 



ULCER OF THE STOMACH. 233 

examined. If vomiting is absent the gastric contents may be 
obtained for examination with the stomach bucket. The 
examination of the gastric contents by means of any instru- 
ment should be performed with the greatest caution, and only 
in those instances where the diagnosis of gastric ulcer is doubt- 
ful. Whenever there are sufficient symptoms to make the 
diagnosis pretty certain, the employment of an instrument 
should be omitted. Most writers are opposed to the applica- 
tion of the tube in gastric ulcer. 

Latent Ulcer. — All the above symptoms of gastric ulcer may 
at times be missing, and the sickness may remain concealed. 
It is well known that scars resulting from ulcer are found at 
autopsies in the stomachs of people who apparently never had 
any gastric trouble. 

The following is a good example of an ulcer without typical 
subjective symptoms, showing at the same time the importance 
of hemorrhage as a diagnostic sign: 



Mrs. H , 44 years old, has been complaining for the 

last five years of frequent belching, poor appetite, and con- 
stant pains of a very slight character in the epigastric region. 
Patient never had any hemorrhage nor any intense pains, and 
her bowels were always regular. Dming her illness she has 
lost eight pounds, and looks extremely pale and anaemic. 
The examination of the abdomen reveals the position of the 
stomach between the navel and one finger's width above the 
pubes. There is no pain on pressure either in the epigastric 

_ stric region, although the epigastrium is somewhat sensi- 
tive to pressure. Right kidney movable. Examination with 
the tube one hour after the test breakfast results in the with- 
drawal of coffee-colored contents mixed with fine particles of 
bread; the microscope shows numerous red blood corpuscles; 
the chemical analysis of the filtrate reveals HC1 + acidity = 70. 



234 DISEASES OF THE STOMACH. 

On the next day the patient's stools were black from admix- 
ture with blood. 

The diagnosis of gastric ulcer was made and the patient 
treated accordingly. She gradually recuperated, and under a 
further tonic treatment entirely recovered, and has remained 
free from any symptoms for the last two years. 

Again, such a latent ulcer may sometimes suddenly give 
rise to alarming symptoms, and even cause death from perfora- 
tion or a profuse hemorrhage. 

Duration of the Disease. — The duration of gastric ulcer is 
sometimes extremely long. Brinton cites cases in which the 
sickness had lasted from thirty to thirty-five years. 

Complications. — Complications quite frequently appear dur- 
ing the protracted course of this affection. These may com- 
prise a sudden exacerbation of one of the usual symptoms, as 
for instance the pain or vomiting, which may become uncon- 
trollable, and hemorrhage, which may become fatal in a few 
hours or even in a few minutes. Again, they are sometimes 
caused by intercurrent phenomena. 

Perforation. — The most dangerous complication of gastric 
ulcer is perforation, which is due to an extension of the ulcera- 
tive process through the whole stomach wall to the peritoneum. 
It is followed by sloughing or rupture of these delicate mem- 
branes, and by the effusion of the contents of the stomach into 
the peritoneal cavity. The perforation is accompanied by very 
intense and characteristic symptoms. The patient is suddenly 
attacked by a violent pain, which begins in the epigastric 
region, and rapidly spreads over the abdomen. Sometimes 
the patients have a sensation as if something had given way in 
their abdominal cavity, and a gush of liquid had occurred. 
Symptoms of general peritonitis now quickly appear. In a 
short time the whole abdomen becomes greatly distended and 
extremely painful to the slightest touch. Entrance of gas into 



ULCER OF THE STOMACH. 235 

the abdominal cavity occurs, in consequence of winch the dul- 
ness of the liver sometimes disappears; at times, again, emphy- 
sema of the skin develops. The extremities become cold, while 
the temperature of the body rises. The pulse becomes very 
small and can hardly be counted. A cold sweat breaks out on 
the face, which wears an expression of extreme anxiety (facies 
Hippocratica) ; singultus is present, as a rule, while vomiting 
may at times be absent (in those instances where the entire 
contents of the stomach have escaped into the abdominal 
cavity). After a short period of coma the patient usually dies. 
Rarely does the train of symptoms following perforation offer a 
marked deviation from the above description. In many 
instances, a remarkable paroxysm of pain precedes the occur- 
rence of perforation. This pain, the duration of which varies 
from a few minutes to several hours, is generally due to a leak- 
age of the gastric contents through the thin film of rotten 
tissue, to which at this period the coats of the stomach are 
reduced. Partial perforation, allowing of a subsequent repeti- 
tion of the accident, or leading to abscess, presents symptoms 
of a more local, more chronic, and less intense character than 
those of ordinary perforation. Perforation nearly always 
occurs after a full meal, and is often traceable to mechanical 
violence, such as coughing, sneezing, or constriction of the 
abdomen. 

Sometimes, before the perforation arises, an adhesive inflam- 
matory process takes place, in consequence of which the 
stomach in the affected area becomes adherent to neighboring 
organs, a process which may then prevent the entrance of 
the gastric contents into the peritoneal cavity. A local abscess 
is very often the result of such an occurrence. This form of 
abscess may open into different cavities; thus, for instance, a 
fistulous opening between the stomach and the colon, or the 
stomach and the abdomen, has frequently been found estab- 
lished. Again, the abscess may perforate the diaphragm and 



236 DISEASES OF THE STOMACH. 

lung, and be evacuated in this way. As these instances are not 
so very frequent, 1 will here mention a case of this kind which 
I observed many years ago. 



A lady, about 30 years old, after a short period of slight dyspep- 
tic symptoms, was suddenly attacked with profuse gastric hemor- 
rhages. On the first day she vomited about one pint and a half 
of almost clear blood, the vomiting being accompanied by severe 
pains in the gastric region. She was kept in bed, an ice-bag 
applied to her abdomen, and large doses of opiates were 
administered. On the following day the hsematemesis was 
repeated. Under the above treatment, however, the patient 
began slightly to improve and to take small quantities of milk. 
About a week after the first hemorrhage she suddenly experienced 
a more intense pain in her abdomen, followed by all the symptoms 
of severe collapse. Singultus appeared, the abdomen swelled, 
and became extremely painful to the touch, while the tempera- 
ture rose to 104°, the pulse to 140, and the extremities grew cold. 
The diagnosis of perforation of the ulcer was quite clear, and the 
patient was believed to be dying. This critical state remained 
unchanged for about four or five days, when suddenly the dyspnoea 
which had before existed in a slight degree, increased, while the 
expired air assumed a very offensive odor. This symptom in- 
creased to such a degree that it was hardly possible to sit in the 
same room with the patient. About two days later, during 
which period the offensive smell constantly persisted with undi- 
minished strength, the patient brought up during several spasmodic 
coughing-spells about one pint and a half of pus, in which parti- 
cles of casein and small black flakes could be clearly seen. This 
matter had exactly the same odor as the air expired by the pa- 
tient for the last two days. Immediately after this occurrence the 
expired air entirely changed its character, and the atmosphere of 
the room was no longer unpleasant; the patient began to feel 
better, the temperature fell, all the symptoms of peritonitis began 
to disappear, and she made a slow recovery in about six weeks. 
In this case after the perforation of the stomach there must have 
formed a localized abscess, which extended through the dia- 
phragm into the lung and emptied itself through a bronchus. 



ULCER OF THE STOMACH. 237 

By a similar process an abscess may form beneath the 
diaphragm, and may at times cause a condition which Leyden 1 
designated as "Pyopneumothorax subphrenicus" on account of 
its similarity to the real pyopneumothorax. This condition 
appears only when gas is contained in the abscess. Debove 
and Remond 2 designate it by the more correct term " gaseous 
subdiaphragmatic abscess," while in this country it is briefly 
called ; ' subphrenic abscess." The abscess is, as a rule, situated 
toward the right side. Its walls are formed by the diaphragm 
above, by the liver and the stomach below; to the right it is 
surrounded by the suspensory ligaments of the liver, and to the 
left by the spleen. The liver is usually pushed downward and 
the diaphragm upward. Thick false membranes form the 
walls of the abscess, which contains gas and fetid liquids, the 
latter being composed of pus and alimentary residues. 

The symptoms that are caused by this condition are: the 
respiratory vibrations of the lower part of the thorax disappear; 
the liver dulness in the back and the lower part of the lung are 
replaced by a zone giving a tympanitic sound on percussion. 
On auscultation the respiratory sounds are not audible, but 
there are heard instead succussion sounds of a metallic pitch. 
The best diagnostic sign of this condition is afforded by explor- 
atory puncture, by means of which one can aspirate pus con- 
taining some food particles. Another diagnostic point of value 
has been suggested by Pfuhl, 3 and consists in connecting the 
exploratory needle with a manometer. The pressure in this 
affection is greater during inspiration and less during expiration, 
whereas in real pyopneumothorax this condition of pressure 
will be found reversed. Of late this disease has been recognized 
during life and successfully operated upon by incision of the 

1 E. Leyden: "Ueber Pyopneumothorax subphrenicus und subphren- 
ische Abscesse." Zeitechr. f. klin. Med., 1880, p. 320. 

2 Debove el Remond: I c, p. 272. 

•Pfuhl: Berliner klin. Wochenschrift, 1877, p. 57. 



238 DISEASES OF THE STOMACH. 

abscess and cleansing of the cavity. C. Beck/ of New York, 
reported three successfully operated cases of subphrenic 
abscess. 

The local abscess caused by perforation can also at times pro- 
duce other complications; thus, for instance, it may perforate 
the abdominal wall, with establishment of a fistulous opening 
from the stomach to the outside. Although very rare, cases 
are also mentioned in which an abscess of the stomach has 
perforated the pericardium, and even the heart itself, causing 
death. 

As regards the frequency of perforation in the course of 
gastric ulcer, it occurs, according to Brinton, in not more than 
one out of seven or eight cases of this lesion; while sex has no 
influence upon the frequency of its occurrence, the age of the 
patient seems to play an important part in this respect. 

Although gastric ulcer is met with more frequently as life 
advances, the occurrence of perforation, on the contrary, 
declines from the age of 30 to that of 70. According to Brinton, 
the distribution of the liability to perforation over the whole 
life varies materially in the two sexes. In the female about 
one-half of the number of cases occur between the ages of 14 
and 30, one-third in the six years between 14 and 20. In the 
male the distribution is constant up to the age of 50, and di- 
minishes but little up to that of 70. The average age of those 
subject to perforation also differs in the two sexes, being 27 in 
the female, 42 in the male. The situation of the perforating 
ulcer plays the chief part in the frequency of this occurrence. 
The anterior surface of the stomach, though much more rarely 
affected by ulcer, is yet one of the most frequent sites of perfo- 
ration. According the Brinton, in all other situations of the 
ulcer, the probabilities are about 60 to 1 against perforation, 
while in the anterior surface of the stomach, they are 6 to 1 in 

J C. Beck: Medical Record, February loth, 1896. 



ULCER OF THE STOMACH. 239 

its favor. The reason for this is the circumstance that the 
front wall of the stomach is more exposed to motion than all 
other parts of the stomach where ulcer is usually found. The 
mobility of this part prevents the formation of adhesions, which 
often form if the ulcer is situated elsewhere. 

The gastric ulcer is liable to bring in its train still other com- 
plications: thus in some instances a cancer may be developed 
on the base of an ulcer or on its scar. Dittrich was the first to 
describe this complication, and Rosenheim 1 has latety published 
several important investigations on this subject. The same 
writer 2 has also described another complication of chronic 
gastric ulcer, and that is a grave form of anaemia, which may 
be styled "pernicious." 

Pulmonary tuberculosis is a frequent occurrence in gastric 
ulcer, as in many other chronic diseases, and hastens the death 
of the patient. It does not seem, however, that there is a more 
intimate connection between these two affections than obtains 
in other diseases. 

As mentioned above in speaking of the pathology of the ulcer, 
severe complications may arise from the thickening of a cicatrix, 
especially if situated at the pylorus, or very near it, or again at 
the cardia. In the first instance, the most frequent complica- 
tion is stenosis of the pylorus with dilatation of the stomach, 
which will be treated in a special chapter under Ischochymia; 
in the second, stricture of the cardia, causing dysphagia. 

Diagnosis. — In cases where all the symptoms of gastric ulcer 
are present no difficulty will be experienced in the diagnosis. 
It frequently happens, however, that only one or two of the 
above-described symptoms exist, and it is then more difficult 
to make a positive diagnosis. One of the following symptoms, 



1 Th. Rosenheim: "Zur Kenntniss des mil Kreba eomplicirten runden 

geschwurs." Zeitschr. f. klin. Med., Bd. 17. p. 11(>. 

2 Th. Rosenheim: Deutsche med. Wbchenschr., 1890, No. 15. 



240 DISEASES OF THE STOMACH. 

if present in its characteristic form, will suffice to establish a 
probable diagnosis of ulcer. 

1. Hxematemesis. If the quantity of blood vomited be 
quite large, and cancer of the stomach or cirrhosis of the liver 
can be excluded. 

2. Pains. Pains appearing shortly after meals, and lasting 
for a considerable time (two to three hours), being influenced 
by the quantity and quality of food in such a way that they are 
most intense after the ingestion of coarse substances in large 
quantities, without perfectly free intervals of several days' 
duration, are sufficient to warrant the suspicion of gastric ulcer. 
If in connection with this spontaneous pain there is a circum- 
scribed spot in the epigastric region that is painful to pressure, 
or if there is a small area likewise painful to pressure to the 
left of the eighth or ninth dorsal vertebra, then the diagnosis of 
an ulcer becomes probable. 

3. Vomiting. Vomiting appearing shortly after meals and 
preceded by a period of uneasiness in the gastric region, may 
also at times be suspicious of gastric ulcer. If this occurs in 
individuals who have lately grown much paler and more anaemic, 
the suspicion again becomes a probability. This probability 
is still greater if the gastric contents show a too high degree of 
acidity and the presence of occult blood. 

Differential Diagnosis. — Very often cases of pure nervous 
gastralgia, of hyperchlorhydria, and of cancer present symp- 
toms similar to those of gastric ulcer, and in making the diagno- 
sis we shall have to take all these affections into consideration. 
Following Ewald's example, I deem it best to give all points of 
differential diagnosis between the above-named conditions in 
a table: 



ULCER OF THE STOMACH. 



241 



Gastric ulcer. 

1 


Nervous 
gastralgia. 


Hyper- 
chlorhydria. 


Cancer. 


Age 


Rare in youth, fre- 


Most frequent 


Met with in all 


Middle age and ad- 




quency increasing 


between the periods of life, 


vanced life. 




progressively from 


ages of IS to 


except in 






puberty to a very 


35. 


youth, when it 






advanced age. 




is quite rare. 




Sex 


More frequent in 


More frequent More frequent 


No marked differ- 




women (2:1). 


in women. 


in men. 


ence between the 
two sexes. 


Epigastric 


Quite intense; ap- 


The pain ap-The pain ap- 


The pain is less in- 


pain. 


pears shortly after 


pears without 


pears about 


tense in character 




meals; grows se- 


regularity and 


two to three 


but more steady; 




verer on pressure; 


is not in any 


hours after 


there are seldom 




disappears at the 


way depend- 


meals and dis- 


free intermissions 




end of the digest- 


ent upon the 


appears after 


during which no 




ive period; sel- 


meals; is 


partaking of 


distress is felt in 




dom perfectly free 


relieved b y 


some food (es- 


the gastric region. 




periods. 


pressure and 
shows inter- 
vals of several 
days' dura- 
tion which are 
perfectly free 
from pain. 


pecially meat, 
milk, egg) or 
after the ad- 
ministration 
o f bicarbo- 
nate of soda. 




Appetite 


Appetite not impair- 


Variable Often increased. Appetite, as a rule, 




ed, although pa- 






very poor. 




tient as a rule eats 










less on account of 










his suffering. 








Tongue 


Dry and red, show- 


Presents a nor- Is either clean Almost always thick- 




ing a white stripe 


mal appear- or slightly 


ly coated. 




in the middle, or 


ance. 


furred. 






smooth and moist 










or slightly furred. 








Taste 


Nothing abnormal.. . 


do. 


do. 


Very often bitter or 
sour. 


Belching .... 


As a rule absent; if 
present, without 
any bad odor. 


do. 


do. 


As a rule present 
and very often 
associated with a 
disagreeable, even 
fetid odor. 


Regurgitation. 


At times present, 


Not present . . . Water brash 


No water brash; py- 




frequently water 




and pyrosis 


rosis quite intense. 




brash associated 




quite fre- 






with pyrosis. 




quent. 




Vomiting .... 


Appears in some 


.Shows no regu- No vomiting. . . 


The vomiting, as a 




cases soon after 


larity in its 




rule, occurs not 




meals. 


appearance. 




after each meal, 
but once or twice 
a day or once in 
two days, the 
quantity being 
often very large. 



16 



242 



DISEASES OF THE STOMACH. 





- , . . Nervous 
( instric ulcer. . . . 


Hyper- 


Cancer. 




gastralgia. 


chlorhydria. 




Htematemesis. 


Vomiting of a large 


No vomiting of 


No vomiting of 


Vomiting of blood 




quantity of blood, 


blood. 


blood. 


occurs; the 




either clear red or 






quantity is rela- 




of coffee - ground 






tively small, the 




color. Blood is 






color ordinarily 




also found in the 






coffee brown. 




stools. A repeti- 






The blood ap- 




tion of the hsema- 






pears in a decom- 




temesis may occur 






posed condition, 




on the following 






presenting fre- 




day, but if once 






quently a fetid 




arrested it does 






odor. The vomit- 




not reappear for 






ing often recurs 




quite a long period. 






with short inter- 
missions. 




i 1. Gastric juice as 


Variable 


Increased 


As a rule, highly 


Secretory func- 


a rule in - 
< creased. 






decreased. 


tion 










2. Lactic acid ab- 


Absent 


Absent 


As a rule, present. 




[ sent. 








Tumor 


No tumor; rarely, 
however, if the 
ulcer is near the 
pylorus, the latter 
becomes thickened 
and can be felt as 
a smooth, lengthy 
body. 


No tumor 


No tumor 


Tumor very fre- 
quently palpable; 
presenting, as a 
rule, an uneven 
surface; is pain- 
ful to pressure 
and easily mov- 
able. 


Perforation. 


Perforation might 
take place after a 
short period of ill- 
ness. 


No perforation. 


No perforation. 


Perforation occurs 
only in the last 
stages of the dis- 
ease. 


Complexion. 


Complexion c o m - 


Complexion 


Complexion 


Complexion sallow 




monly fresh, but 


pale. 


pale. 


and yellowish ; 




an8emic after se- 






skin dry; marked 




vere losses of 






cachexia. 




blood. 









Localization of the Ulcer. — As above mentioned in speaking 
of the pathology, the ulcer may be situated at different points 
of the stomach walls, or at the pylorus, the beginning of the 
duodenum, the cardia, or the lower end of the oesophagus. The 
exact site of the ulcer can be determined with certainty only 
in rare instances. Most frequently we remain in doubt with 
reference to this point of diagnosis. There are, however, 
several symptoms which can be utilized with regard to a prob- 



ULCER OF THE STOMACH. 243 

able diagnosis as to the situation of the ulcer. 1. Frequently 
patients experience relief from their pains in assuming a certain 
position. Thus, for instance, some feel easier in lying on the 
back, others less uncomfortable when they He upon their abdo- 
men. Again, some -feel no pain in standing, but the latter 
appears when they assume a recumbent position. In a few, 
again, this is reversed, the pain appearing in the standing and 
disappearing in the recumbent position. As a rule, we may 
assume that the position in which the patient is most comfort- 
able is the one which permits the ulcer to remain above the 
gastric contents, and to come least in contact with them. 
Hence an ulcer situated at the lesser curvature will be diagnosed 
if the patient experiences relief in standing. Again, an ulcer 
of the greater curvature will be suspected if the pain is most 
intense on standing. The site of the ulcer will be suspected to 
be in the cardiac portion of the stomach if the patient has less 
pains when lying on his right side, and in the pyloric region if 
the pains are less severe when he occupies a left-sided position. 
2. Pains appearing directly after the deglutition of food, and 
associated with vomiting immediately after meals, particularly 
point to an ulcer in the cardiac region or in the lowest part of the 
oesophagus. 3. Pains appearing two or three hours after meals, 
referred partly to the right of the epigastric region and associ- 
ated with melaena (bloody stools), point to the situation of the 
ulcer either at the pylorus or the beginning of the duodenum. 
Another aid in the diagnosis and localization of gastric ulcers is: 
4. The thread impregnation test 1 (Einhorn). The method 
consist- in the following: The patient swallows the duodenal 
bucket in a gelatine capsule about 9 p.m. The thread which 
is of braided silk (English, Xo. 5) is attached to the shirt in 
such a manner that it can pass through the digestive tract for a 
distance of 75 cm. from the lips. The bucket is left in the 

'Max Einhorn: "A New Mothod of Recognizing Floors of t ho Upper 
_ tive Tract and of Localizing Them. - ' Medical Record, April 3d, 1909. 



244 DISEASES OF THE STOMACH. 

digestive apparatus over night and is removed about 7 or 8 a.m., 
in the fasting condition. At the pylorus we often experience 
a slight resistance which is usually easily overcome; a greater 
resistance is offered at the larynx at the entrance of the oesopha- 
gus. Here the patient must swallow and while the larynx 
moves upward the bucket may easily be drawn out. The 
thread is then closely inspected. In favorable cases of ulcer, 
particularly if the thread has come into intimate contact with 
the surface of the ulcer, we find a brown or dirty black discolor- 
ation of the thread at this point. The distance of this brown 
spot from the lips points to the seat of the ulcer. A blood stain 
in the neighborhood of 40 cm. points to an ulcer at the cardia; 
at 44 to 54 cm., ulcer of the lesser curvature; 56 to 58 cm., 
pylorus; 59 and more, ulcer in the duodenum. 

Ulcers situated in the oesophagus, cardia, lesser curvature, 
pylorus, and duodenum can best be recognized by this method, 
whereas ulcers of the fundus and the greater curvature cannot 
be discovered by this test. 

Prognosis. — At first glance it would appear that the prognosis 
of gastric ulcer is quite good, especially nowadays, when the 
diagnosis of the affection is usually made at an early date. 
However, if we take into consideration the tabulated statistics 
given by Debove and Remond 1 in reference to the outcome of 
all cases of ulcer, we will become more careful in our favorable 
predictions. This table gives in a hundred cases of ulcer: 

Perfect cure, 50 

Perforations and peritonitis, 13 

Foudroyant haematemesis, 5 

Pulmonary tuberculosis, 20 

Inanition, 5 

Different complications, 7 



The attached figure shows the result of the thread test in 
patient R. J., with gastric ulcer. 

1 Cited from Debove et Remond: I. c, p. 276. 



ULCER OF THE STOMACH. 



245 



Treatment of Gastric Ulcer. — Cruveilhier, to whom we are 
indebted for the first thorough and accurate description of 




76.— Duodenal Bucket with thread, after a night's stay in the digestive tract of 
K. .1.: '/. after ordinary foods; b, after a week's treatment wit h b strictly liquid diet. 
The arrow marks the place where the blood stain begins. 



240 DISEASES OF THE STOMACH 

gastric ulcer, recommended milk as the most suitable food in 
this condition, and although many decades have since passed, 
milk still stands first in the dietary of these patients. 

As rest is the foremost auxiliary in the treatment of most 
diseases, it appears natural to make use of this agent in ulcer. 
Leube and Ziemssen 1 deserve credit for having laid so much 
stress on this point and for having devised the "rest cure" for 
the treatment of ulcer. Although this mode of treatment, had 
been practised long ago by W. Fox 2 and B. Forster in England, 
still Leube and Ziemssen have succeeded in popularizing the 
same, and that is the reason why it justly bears their name. 

The Leube-Ziemssen rest cure for the treatment of ulcer con- 
sists in the following: The patient is kept abed for two to three 
weeks. He is poulticed during the- day with flaxseed (warm) 
over the stomach and the upper part of the abdomen; at night 
a priessnitz (wet linen cloth) is substituted, covering the same 
area. The diet consists of liquids — milk, milk with strained 
barley, or oatmeal, or rice water, plain water, weak tea, and 
peptone (one teaspoonful to a cup of water). Debove and 
Remond 3 have suggested the addition of lactose and of meat 
powder to the milk, in order to make the diet richer in nourish- 
ing substances. As a rule, we employ the above-named addi- 
tions, which fulfil the same purpose, besides varying the 
monotonous bill of fare. 

During the first week we give the patient half a cup (about 
100-150 c.c.) of either every hour. Everything the patient 
takes must be neither cold nor very warm, and should be taken 
slowly (sipping or with a spoon). During the second week 
we order the same kind of food, with this difference, that he is 
nourished every two hours, and gets a cupful or a cupful and a 
half (200-300 c.c.) at a time. Occasionally we now allow the 

1 Leube: I. c, p. 120. 

2 Wilson Fox: I. c 

3 Debove et Remond: I. c, p. 284. 



ULCER OF THE STOMACH. 247 

patient one raw egg beaten up in the milk, once or twice a day. 

In the beginning of the third week we feed the patient every 
three hours ; he is allowed barley, farina and rice (well cooked) 
in milk, soft-boiled eggs, crackers softened in milk, in addition 
to his previous food; on the third day of the third week we begin 
to give the patient meat, first raw, well scraped, then broiled. 
Thereafter we go over to the ordinary daily diet, excluding 
heavy salads, pastry, raw fruit, and the like. 

In the following table I give an outline of diet which I ordi- 
narily prescribe in this affection: 

Outline of Diet in Gastric Ulcer. 



FIRST THREE DAYS. Number of 

calories. 

7 a.m.: milk, 150 c.c. (five ounces), 101 

8 a.m.: milk, 150 c.c. (five ounces), 101 

9 a.m.: milk, 150 c.c. (five ounces), 101 

10 a.m.: milk and strained barley water (aa), 150 c.c, ....... 80 

11 a.m.: milk, 150 c.c, 101 

12 xoox: milk, 150 c.c, 101 

1 p.m.: bouillon either alone or with the addition of one to two 

teaspoonfuls of a peptone preparation, 150 c.c, 30 

2 p.m.: milk 101 

3 p.m.: milk, 101 

4 p.m.: milk, 101 

5 p.m.: milk with strained barley or oatmeal, 80 

6, 7, 8, 9 p.m.: milk, 150 c.c, 404 

1,402 



FOURTH TO THE TEXTH DAY. Number of 

calories. 
7 a.m.: milk, 300 c.c. (ten ounces), 202 

a.m.: milk, 300 c.c, 202 

11 a.m.: milk, with barley, rice, or oatmeal water, 300 c.c, 160 

1 p.m.: one cup of bouillon, 200 c.c, and one egg beaten up in it, . 80 
3 p.m.: milk, 300 c.c, 202 

6 p.m.: milk, 300 c.c, 202 

7 P.M.: milk, with barley water, 300 c.c, 100 

9 p.m.: milk, 300 c.c, 202 

1,410 



248 DISEASES OF THE STOMACH. 

ELEVENTH TO THE FOURTEENTH DAY. Number of 

calories. 

7 a.m.: milk, 300 c.c, 202 

9 a.m.: milk, 300 c.c, 202 

and two crackers softened (one ounce), 100 

11 a.m.: milk with barley water, 300 c.c, 160 

1 p.m.: one cup of bouillon, 200 c.c, one egg, and two crackers, . . 180 

3 p.m.: milk, 300 c.c, and one egg, 282 

5 p.m.: milk, 300 c.c, 202 

and two crackers, 100 

7 p.m.: milk with barley water, 160 

9 p.m. : milk, 300 c.c, 202 

1,790 

FOURTEENTH TO THE SEVENTEENTH DAY. Number of 

calories. 

7 a.m.: milk, 300 c.c, 202 

9 a.m.: milk, 300 c.c, 202 

and two crackers (one ounce), 100 

11 a.m.: milk with barley, 300 c.c, . 342 

1 p.m.: scraped meat, 50 gm., 6Q 

two crackers; one cup of bouillon, 200 c.c, 100 

3 p.m.: milk, 300 c.c, 202 

5 p.m.: milk, 300 c.c, 202 

one egg (soft boiled), 80 

two crackers, 100 

7 p.m.: milk with farina, 300 c.c, 342 

9 p.m. : milk, 300 c.c, 202 

2,134 

SEVENTEENTH TO TWENTY-FOURTH DAY. Number of 

calories. 

7 a.m.: two eggs (soft boiled), 160 

butter, 10 gm., 81 

toasted bread, 50 gm., 130 

milk, 300 c.c, 202 

10 a.m.: milk, 300 c.c, 202 

crackers, 50 gm., 166 

butter, 20 gm., 162 

1 p.m.: lamb chops (broiled) 50 c.c, 60 

mashed potatoes, 50 gm., 44 

toasted bread, 50 gm., 130 

butter, 10 gm.; one cup of bouillon, 200 c.c, 81 

4 p.m.: the same as at 10 a.m., 530 

6:30 p.m.: milk with farina, 300 c.c, 342 

crackers, 50 gm., 166 

butter, 20 gm., 162 

9 p.m.: milk, 300 c.c, _202 

2,820 



ULCER OF THE STOMACH. 249 

This diet has the advantage that, from the tenth day on, an 
almost sufficient nourishment is given. For about seven years 
I 1 have used the same diet as described with the addition of raw 
eggs from the beginning. 

I usually give from the very first day raw eggs in milk or in 
bouillon. On the first day two eggs, then increasing one egg a. 
day until eight eggs daily are consumed. In this way the 
caloric food value is increased, and we can easily make the 
patients gain weight if desired. After two weeks of treatment 
meat, soft-boiled eggs, farina, and zwieback are also given. 
Seventeen days after treatment the patients are living on a, 
mixed diet which very closely resembles their usual mode of 
life. The results attained with this treatment have been very 
good. 

Lehnhartz's Diet. — The method is distinguished from the 
usual dietic treatment in that even in haemorrhage food is given 
at once and that meat is added very quickly. Lehnhartz's 
directions, as given by Wagner, 2 are as follows: "On the day of 
the haemorrhage the patients receive daily from 200 to 300 c.c. 
iced milk in spoonful doses and from one to three fresh eggs, 
beaten; in addition bismuth is given from two to three times 
daily. The quantity of milk is increased by 100 c.c. daily and 
by one egg, so that at the end of the first week about 800 c.c. 
of milk and from six to eight eggs are taken daily. Six days 
after the haemorrhage finely scraped raw beef is given, for a day 
or two, thirty-five grams in small portions mixed with egg, 
later seventy grams and more, in gradually increasing quan- 
tities. After fourteen days rice and farina gruels and soft zwie- 
back; after from three to four weeks a plentiful mixed diet." 



'Max Einhorn: "The Treatment of Gastric Ulcer." X. Y. Medical 
Journal. Nov. 20th, 1909. 

'Max Wagner: "Zur Behandlung dea Magengeschwtirs." Miinchener 
medizinische Wochenschrift, 1904, p. 3. 



250 DISEASES OF THE STOMACH. 

In this country Lambert 1 has been an ardent advocate of 
the Lehnhartz treatment. Lambert treated eight cases accord- 
ing to this method and is well satisfied with the result. He 
expresses himself as follows: "This series does warrant the 
conclusion that the original claims of Lehnhartz are correct: 
First, that the cure is at least equally as efficient as the older 
method, and that it does not deplete the patient; second, that 
the cure is more rapid as well as more certain; third, that the 
vomiting and bleeding stop more quickly and recur less fre- 
quently than in the Leube cure; fourth, that the pain ceases 
promptly and that morphine is never needed; fifth, that the 
food supply is sufficient throughout; sixth, that it is possible to 
treat the anaemia earlier with iron and arsenic than in the Leube 
cure; and seventh, that it is possible to return to a full diet and 
to the patient's usual occupation earlier than in the older cure." 

As can be inferred from the literature on the Lehnhartz 
method, we do not always have to adhere strictly to the absti- 
nence cure even in haemorrhage, but can safely give some food 
in suitable cases. Usually nutrition is not so low, that the 
small quantities of food given by Lehnhartz immediately after 
haemorrhage and which by most clinicians are given rectally, 
make much difference. In nonbleeding ulcers I consider the 
usual Leube diet or the one modified by myself as more suitable. 
Meat, which plays so important a role in the Lehnhartz diet, is, 
in my opinion, for the first period of treatment not as suitable 
as the other varieties of albumin. Meat, as is well known, is a 
strong stimulant of gastric secretion and it takes some time 
before it is liquefied by the gastric juice — usually this 
does not take place in the stomach, the meat passing out of the 
pylorus in a swollen state. Inasmuch as in the first period of 
treatment rest is all important for obtaining a cure, meat will 
not answer this requirement. Another point mentioned by 

1 S. Lambert: "The Lehnhartz Treatment of Gastric Ulcer." American 
Journal of the Medical Sciences, 1908, p. 18. 



ULCER OF THE STOMACH. 251 

Lehnliartz and his pupils that with the usual milk diet the 
amount of fluids is too large and causes a dilatation of the 
stomach, I do not think justified, as with a careful use of the 
diet I have never seen any bad consequences. 

At the beginning of the third week the flaxseed poultices are 
discontinued and the patient is allowed to be up, first for a short 
time only (half an horn* to an horn), then for several hours, and 
afterward for the whole day. At the beginning of the fourth 
week the patient may begin to walk outdoors and gradually 
resume his daily work. 

Leube and Ziemssen and most of the German writers recom- 
mend the use of either Carlsbad water (half a pint) or Carlsbad 
salt. 5 to 10 gm. in the same quantity of water, heated to 122° 
F., twice daily (the first portion being taken in the morning, the 
second at night before going to sleep). I do not believe that 
the Carlsbad salt is in any way essential. In most of my cases 
of gastric ulcer I have omitted the so-called Carlsbad drink cure, 
and have obtained results equally satisfactory as when the salt 
was employed. 

In cases of ulcer of the stomach presenting a more severe 
type — violent pains, frequent vomiting, inability to take food 
on account of the pains — or after haematemesis, I usually have 
the patient abstain from any food whatever, given by the 
mouth, for a period of five days. The patient is then fed by 
the rectum. This is done in the following way: Early each 
morning the patient receives a large enema of about -a quart 
of lukewarm water in which a teaspoonful of common table 
salt has been dissolved as a cleansing enema. About an hour 
after the patient has emptied the injected water the first 
nourishing enema is given; this may consist either of a glassful 
of milk ("about 200 c.c.) in which a raw egg has been well bent en 
and a pinch of salt added, or of a cupful of water in which a 
tablespoonful of a good peptone preparation has been dissolved. 
The temperature of either must be about 100° F. Such a 



252 



DISEASES OF THE STOMACH. 



nourishing enema is given three or four times a day. The 
quantity of the feeding enema is 200-250 c.c., and it is slowly 
injected by means of a fountain syringe and a soft-rubber rectal 
tube. The patient may frequently wash his mouth with cold 
water, and is allowed from time to time to keep a small piece of 




Fig. 77/ — The Duodenal Feeding Apparatus, with Table Support. A, tube leading to 
syringe; B, tube leading to duodenal pump; C, crank; D, tube leading to fluid; F, fluid; G, 
glass; T, table support or shorter support. When crank C is turned parallel to A, fluid 
can be aspirated from the glass into the syringe. When C is moved parallel to B, the fluid 
from the syringe can be emptied into the duodenum. 

chopped ice in his mouth, and to swallow the melted water and 
to take a little gelatin. The five days being over, the mode of 
diet is the same as described above for the ordinary form of 
ulcer. 

Another and more efficient way of giving the stomach perfect 



ULCER OF THE STOMACH' 



253 



rest is duodenal alimentation. The method consists in insert- 
ing the duodenal pump into the digestive tract. When the 
latter has reached the duodenum, nourishment is injected into 
this part of the gut. The instrument is then left in situ from 
ten to fourteen days and nourishment given through it. It 
was shown by me 1 that this is a feasible method of feeding and 
that it is possible to nourish the organism by this means without 
much loss of flesh. 




Fig. 78. — Patient being fed through the duodenum. 

I have had the opportunity of employing this method of 
alimentation in 20 cases. 

The injection of the food can be facilitated by the use of a 
specially constructed support for the duodenal feeding appara- 
tus, as illustrated in Fig. 78. 

The feeding is best done at intervals of two hours. After 
the feeding, water is forced through the tube, and finally air 

l M. Einhorn: "On Duodenal Alimentation." Medical Record, July 16, 
1010. 

If. Einhorn: ''Further Pa-marks on Duodenal Alimentation." Inter- 
state Medical Journal, vol. xvii., Xo. 10, 1910. 



J.") I DISEASES OF THE STOMACH. 

blown through and the stopcock is closed. We can introduce 
at one feeding between 240 to 300 c.c. of food slowly. All fluids 
must, of course, be used at body temperature. 

Usually the following nutritive material was used every two 
hours, from seven in the morning until nine in the evening: 
Milk, 240 c.c; 1 raw egg; sugar of milk, 15 gm. The mixture 
well beaten up and injected at blood temperature. The patients 
may be given, besides, a quart of physiological salt solution by 
rectum, according to the Murphy drop method; or receive 
water directly injected into the duodenum, very slowly, drop 
by drop. 

Morgan 1 has also employed duodenal feeding in gastric ulcer 
with success. 

Verbrycke 2 has likewise practised duodenal feeding, when 
rest for the stomach was essential. 

Whenever the "rest cure" is applied there is scarcely any 
need for constant medicinal treatment. Sometimes, however, 
we make use of a small dose of codeine if the pains are very 
severe, and of Carlsbad salt if there is constipation. Only in 
cases where the ulcer is associated with, a hyperacid gastric 
juice may we regularly administer an alkaline salt, as for 
instance : 

1$ Magnes. ust., 5.0 (5i-) 

Sod. carbon, exsiccat., 
Sod. bicarbon., 

Elaeosacch. menth. pip., aa. 15.0 (§ss.) 

M. exactissime, f. pulv. D. ad scatulam. S. A tip of a knife e very- 
two hours. 

In chl orotic individuals the administration of an organic iron 
preparation (as for instance Pizzala's or Dietrich's Elixir of 
peptonate of iron or Boehringer's ferratin) is often very ser- 

1 Wm. Gerry Morgan: "The Diagnosis of, and the Feeding in, Gastric 
Ulcer." Medical Record, March 4th, 1911. 

2 J. R. Verbrycke, Jr. : "Late Methods in the Diagnosis and Treatment of 
Gastric Diseases." The Virginia Medical Semi-Monthly, April 7th, 1911. 



ULCER OF THE STOMACH. 255 

viceable. Thus far we have spoken only of patients who can 
submit to the bed treatment. In patients who cannot afford 
to stay in bed, the following two methods, which are at pres- 
ent in vogue, may be tried. I have practised both of them, 
sometimes with good results. 

The one is the "nitrate-of-silver" treatment, the other the 
"bismuth" treatment. During the use of either of these 
remedies the patient is allowed to attend to his business and 
partake of a light diet, in which milk plays a prominent part. 

I. The silver nitrate is given first: 

^ Argent, nitr 0.3 (gr. v.) 

Aq. dest., 180.0 ( Bvi.) 

D. in vitro nigro. S. A tablespoonful in a wineglassful of water three 
times a day, half an hour before meals. 

After having used up this quantity, the dose may be gradually 
increased, prescribing 0.4-0.6 gm. of silver nitrate to 180 of 
water. The silver nitrate may be used in the way mentioned 
for about two or three weeks, and is then discontinued. The 
pains usually disappear after the completion of the first week's 
medication. 

II. The subnitrate of bismuth. The bismuth has been used 
again and again in painful affections of the stomach, the dose 
being from 0.2 to 1.0 gm. several times daily. The French 
physicians recommended the use of much larger doses, giving 
5 gm. three times daily. Fleiner 1 has lately laid much stress 
on the use of large doses of bismuth, suspended in water, in the 
treatment of ulcer, and Rosenheim 2 corroborated his views. 
I had the opportunity of applying this method quite frequently 
and was satisfied with the results. 

We ma}- give the patient from 3 to 5 gm. of bismuth three 

] Fk-inr-r: Verhandl. dea XII. Congresses f. innere Medicin, 1893. 
- Rosenheim: "Die neueren Behandlungsmethoden de.s Magens." Berliner 
Klinik. May, 1894. 



250 DISEASES OF THE STOMACH. 

times a day, to be taken in a wineglassful of water, well shaken, 
half an hour before meals. It is best to have the patient lie 
quietly for about half an hour after having partaken of 
the powder. The bismuth treatment must be continued for 
about two or three weeks without interruption. It is remark- 
able that these large doses of bismuth do not, as a rule, cause 
constipation. In all of my cases with but few exceptions the 
bowels moved every day without the aid of any cathartic 
during the whole time of the bismuth medication. The bis- 
muth treatment in ulcer seems to me to deserve high recom- 
mendation. Olive oil, 1-2 tablespoonfuls before meals, which 
has been highly recommended by Cohnheim, did not prove 
successful in my own practice. 

Hemorrhage. — In cases of hemorrhage from the stomach the 
treatment is the same as in the severe type of ulcer, with the 
exception that ice-cold applications are made over the stomach 
instead of the warm poultices. Perfect rest is here absolutely 
necessary. The patient must keep very quiet and avoid any 
motion whatever; even turning from one side to the other is 
not permissible. The patient should be prohibited all conver- 
sation except it be to indicate his wants. 

If the hemorrhage be profuse or if there are signs that the 
bleeding has not yet come to a standstill, hypodermic injections 
of ergot are advisable. One Pravaz syringe of the following 
should be injected two or three times a day in the gastric region: 

^ Extr. Ergot., 2.5 (oss.) 

Aq. dest., 

Glycerin., aa 5.0 (5i) 

Gelatin may be administered internally, — one tablespoonful 
of a ten-per-cent. solution being given every three hours, — or 
subcutaneously. In the latter case 100 gm. of a two-per-cent. 
watery solution of gelatin are injected hypodermatically. 

Suprarenal capsule in 3 to 5 gr. doses, principally in the form 



ULCER OF THE STOMACH. 257 

of suppositories, or adrenalin (Takamine 1:1,000 solution), 
5 to 10 drops t. i. d., may also be advantageously tried. Cal- 
cium lactate, 2 gm. twice daily in a small rectal enema, is also 
of benefit. 

Chloride of iron (5-15 drops in water) and acetate of lead 
0.05 gm., one powder every two hours, which in olden times 
were used so frequently, do not in reality have much effect. 

In case the haematemesis, however, recurs frequently, and 
the patient is running the risk of bleeding to death, Ewald 1 
recommends resort to lavage with ice-cold water. For this 
purpose the pharynx must first be well cocainized, and the 
washing of the stomach then performed with the greatest care. 

Collapse. — In case the patient has sunk into a collapsed 
condition, camphor or ether should be hypodermically injected. 
An enema of warm wine or warm wine with egg should be 
administered, and a hot-water bag applied to the feet. In 
those instances where the high degree of anaemia endangers the 
life of the patient, transfusion of blood was formerly frequently 
resorted to. Nowadays a subcutaneous injection of physio- 
logical salt solution (4 to 6 NaCl to aq. dest. 1,000), in quantities 
from a pint to a litre, is used. The solution and the apparatus 
(fountain syringe) must be thoroughly sterilized, and one or 
two quite thick Pravaz needles used. The solution, warmed to 
blood temperature, is then injected into the subclavicular 
region. 

Perforation. — If perforation has occurred perfect rest is 
absolutely necessary; nothing should be given by the mouth, 
ice-bags should be placed over the abdomen, and large doses of 
opium, preferably in the form of suppositories, should be 
administered. In cases in which the stomach contains large 
quantities of food, Ewald suggests the washing out of the 
stomach, performed after cocainization of the pharynx and 
with all other necessary precautions. As soon as the symp- 

1 C. A. Ewald: I. c, p. 274. 
17 



258 DISEASES OF THE STOMACH. 

toms of collapse appear, the above-described treatment is 
employed. The prognosis of perforation being so very unfavor- 
able, notwithstanding all medicinal treatment, resort has been 
lately had to laparotomy, in order to master the situation 
surgically. 

A new variety of ulcer of the stomach is the " exulceratio 
simplex (Dieulafoy)" or superficial ulceration of the stomach. 

It has been observed by several clinicians that extensive 
hemorrhages (even lethal) from the stomach may occur even 
when no distinct ulcer can be discovered in this organ. A few 
such cases with autopsies have been reported. The hemorrhages 
have been ascribed to parenchymatous bleeding (Faltenblutun- 
gen). Very small ulcerations causing fatal hsematemesis have 
been observed by Chiari 1 and Murchison. 2 Chiari described a 
case of fatal bleeding from the stomach resulting from the 
erosion of a submucous vein within an abrasion of the mucous 
membrane, only the size of a large barley-corn. Murchison 
reported two cases of fatal hsematemesis from minute ulcers 
perforating a small artery in the coats of the stomach. He 
says: "They are remarkable not only for the minuteness of the 
ulcers, which are little more than hemorrhagic erosions, but also 
for the absence of the usual symptoms of ulceration of the 
stomach. Neither of the patients had suffered from vomiting 
prior to the occurrence of the hemorrhage." 

Dieulafoy 3 has minutely described a considerable number of 
similar cases of this affection under the heading " Exulceratio 
Simplex." This brilliant clinician gave a most vivid picture 
of the affection in question, which in the main we will make use 
of for our text. The term " superficial ulceration" well 
characterizes the disease under consideration, and may also be 
used with advantage. 

'Chiari: Prager medicinische Wochenschrift, vol. vii., p. 489, 1882. 

2 Murchison: Pathological Transactions, vol. xxi., p. 162, 1870. 

3 Dieulafoy: "Clinquc Medical de l'Hotel Dieu," pp. 1-62, 1899. 



ULCER OF THE STOMACH. 259 

Steven 1 likewise described two cases of severe gastric hemor- 
rhage due to a very superficial abrasion of the gastric mucosa. 
In the middle of the affected area there were two pinhole 
openings through which a bristle could directly be passed into 
one of the primary lateral branches of the gastric artery. 

Definition. — A superficial, usually round, sometimes elliptical, 
loss of substance within the stomach, involving merely the 
mucous membrane and also slightly the muscularis mucosae 
and usually some small blood-vessel/ but not penetrating 
deeper into the other coats of the organ, causing extensive 
hemorrhages. 

Morbid Anatomy. — The exulceratio simplex consists of an 
oval superficial defect of the gastric mucosa, varying in size 
from a five-cent to a fifty-cent piece. The defect involves 
merely the gastric mucosa and also the muscularis mucosae, 
but not the submucous or the other tunics of the stomach. 
The margins of this defect are not indurated and consist of 
almost normal tissue. In the middle of the defect very often 
a minute open blood-vessel is noticeable. Macroscopically the 
exulceration can be discovered at the autopsy or at an operation 
only after a thorough search, the defect being so small that it 
easily escapes notice. Sometimes the ulceration may be situ- 
ated under a fold of the gastric mucous membrane, and for this 
d the rugae must be thoroughly examined. Occasionally 
the affected area is surrounded by a somewhat reddened ecchy- 
motic zone. The microscopical examination shows that the 
defect is due to a disappearance of the gastric mucosa with its 
underlying muscularis. The mucous membrane of the stomach 
is otherwise healthy throughout. The exulceratio simplex has 
no place of predilection and may be situated anywhere within 
stomach. 

'J. L. Steven: "On Profuse Haematemesis due to Tore-like' Abrasion 
of the (iji-tHr- Arteries — No Round Dicer Exulceratio simplex of Dieula- 
foy." Glasgow Medical Journal, p. 5, 1899. 



260 DISEASES OF THE STOMACH. 

Etiology. — The etiology of this affection is not yet known. 
Most probably the exulceratio simplex represents an acute and 
beginning stage of the ordinary ulcer of Cruveilhier. Whether 
a toxic element is the fundamental cause is still uncertain. The 
affection occurs principally in persons of twenty-five to thirty 
years of age. 

Symptomatology . — The disease begins with severe large gastric 
hemorrhages which recur at short intervals. In the midst of 
health the patient is suddenly overcome with vomiting of very 
large quantities of blood (half a litre to one litre), which may be 
also accompanied by melama. Within a few days after the 
onset of the disease, sometimes even within a few hours, the 
patient may be moribund. He resembles a man in whom an 
artery has been opened and who dies from the hemorrhage. 
There is almost always, following the hemorrhage, a rise in 
temperature which is of irregular type and lasts a few days. 
The general symptoms are not much different from those 
encountered after any considerable loss of blood, and consist in 
phenomena of extreme anaemia of the brain, dizziness, light- 
headedness, tinnitus aurium, syncope. The disease very often 
ends fatally as a result of the exsanguination. In some of the 
cases, however, the hemorrhage after having occurred two or 
three times does not reappear, and the patient gradually 
recovers. 

Diagnosis. — A probable diagnosis of exulceratio simplex can 
be made if there have been no gastric symptoms whatever 
previous to the present disease, and there exist extensive hem- 
orrhages from the stomach which recur at short intervals. In 
exceptional cases there may have also been present gastric 
symptoms, like gastralgia, nausea, vomiting. Most frequently, 
however, the hemorrhage appears in the midst of perfect health. 
The differential diagnosis between ulcer of the stomach and 
exulceratio simplex is certainly very difficult and can hardly 
ever be made without a necropsy or an autopsy in vivo. In the 



ULCER OF THE STOMACH. 261 

ordinary ulcer, however, there are always preceding pains and 
other gastric symptoms, and the hemorrhages are as a rule not 
so large. In erosions of the stomach the disease shows a chronic 
type, and there are no profuse hemorrhages. 

Prognosis. — The prognosis of exulceratio simplex is extremely 
grave. 

Treatment. — The treatment of superficial ulceration of the 
stomach coincides with that of gastric hemorrhage. The 
patient should be kept abed, perfectly quiet, with an ice-bag 
over the gastric region, should not be allowed to take anything 
by the mouth, and be nourished by the rectum. Subcutaneous 
injections of normal salt solution should be frequently made. 
Dieulafoy recommends subcutaneous injections of 200-500 gm. 
at a time of the following solution: 

1$ Sodium chloride, 8.0 

Caffeine benzoate, 0.1 

Water, 1,000.0 

Oxygen inhalations and injections of ether and camphor 
must be frequently made when attacks of syncope are imminent. 
In order to favor the arrest of the hemorrhage by means of 
coagulation, subcutaneous injections of a two-per-cent. gelatin 
solution in the amount of 100 gm. at a time can be employed 
with great advantage. I have used this procedure in two cases 
of very severe gastric hemorrhages, one due to an ordinary 
ulcer, the other probably due to a superficial ulceration, with 
good result. It is self-understood that thorough sterilization 
of the gelatin solution and perfect asepsis in the manipulation 
of the injections are required. The injections are best made in 
the gluteal region. 

In cases of a very severe type, Dieulafoy recommends opera- 
tive intervention. The stomach is opened and the superficial 
ulceration when found sutured. The indication for surgical 
intervention exists if the medical treatment proves ineffective, 



262 DISEASES OF THE STOMACH. 

if a copious haematemesis appears at short intervals, andsyncope 
becomes imminent. 

Surgical Procedures in the Treatment of Gastric Ulcer and its 
Sequeloe. — Gastric ulcer may occasionally take a very obstinate 
course, not being amenable to medical treatment. Again, its 
complications, hemorrhage (which may become very abundant 
or frequent) and perforation, greatly endanger life; the latter, 
in fact, almost always terminating fatally. Barling 1 says that 
ninety-five per cent, of the patients having such perforations die, 
unless operated upon. For this reason Nelson C. Dobson 2 in 
1883 advocated operative interference for a perforating ulcer ac- 
cording to one of the following methods. 1. Simple abdominal 
section with cleansing of the peritoneum, leaving the ulcer to 
heal of itself under rest and rectal feeding. 2. The closure 
of the perforation by suture, either with or without paring its 
edges. 3. The suture of the stomach at the point of perfora- 
tion to the abdominal wall, in order to establish a gastric fistula. 

A few years later this mode of treatment was carried out by 
several surgeons in Europe and this country. 

Robert F. Weir, 3 of New York, was among the first who 
operated in this country. His latest report of a successful 
operation of this kind deserves the highest commendation. 
We deem it of great value to report this case in Dr. Foote's own 
words. 

"Mary B consulted me in August, 1894, for an obstinate 

cough, with scanty expectoration and pain in the sternal and 
right scapular region, with dyspnoea on exertion, headache, ano- 
rexia, and constipation. She had twice spit up a small amount 
of blood. For four months she had had night sweats. The 

1 Barling: Birmingham Medical Review, August, 1895. 
Dobson: Bristol Medical and Surgical Journal, 1883, p. 196. 

1 Robert F. Weir and E. M. Foote: "The Surgical Treatment of Round 
Ulcer of the Stomach and its Soquelae, with an Account of a Case Success- 
fully Treated by Laparotomy." Medical News, April 25th and May 2d, 
1896. 



ULCER OF THE STOMACH. 263 

patient was at that time 15 years old, heavy but anaemic. Phys- 
ical examination showed dulness and fine moist rales at the left 
apex, and right base behind, and she had an afternoon fever. 
Under tonic and expectorant remedies, and a month's residence 
in the mountains of Sullivan County, N. Y., she gained weight 
and the rales disappeared, except at the base of the right lung. 
The following winter she neglected herself, and, when I next saw 
her in April, 1895, her cough was worse, and she had moist rales 
over the greater part of both lungs, and she had lost six pounds in 
weight. Though living in poverty, she was able, through friends, 
to spend three months of the summer in the mountains, and she 
did not return to the city until the last of September, 1895, when 
she took a position as maid in an apartment, where the work was 
light and her food good. Her health was excellent, the cough 
and rales had disappeared, and her weight, one hundred and 
ten and a half pounds, was greater than it had ever before been. 
I was never able to secure any sputum for examination, but 
the signs of pulmonary tuberculosis had been too well marked 
to be doubted. 

"She had frequently been troubled with indigestion, and at 
various times had vomited her food, but these symptoms had not 
been prominent ones. About November 20th, 1895, she began 
to have severe gastric pain, and her appetite failed her. She 
spoke to no one about it and kept on with her work, though 
eating almost nothing. The pain, too, was at times so severe that 
she was compelled to lie down. On November 27th, at 10 a.m., 
she was attacked with a colicky pain in the gastric region so 
severe that she rolled upon the floor in agony, and vomited a 
small amount of coffee, which was the only nourishment she had 
taken that day. About noon she felt a little relief and went 
home by way of the elevated road. To do this, she walked about 
a quarter of a mile, and climed up and down some fifty steps. 
Late in the afternoon she sent word to me that she had an 'attack 
of pain in the heart.' At 6 :30 p.m. I found her lying on her back, 
quiet, and without much pain. Pulse, 120; temperature, 102°. 
r l he facies, though not well marked, was of a purely abdominal 
type. The chest revealed nothing abnormal. The abdomen 
a somewhat rigid, and more so on the left side than on the 
right. There was moderate tenderness on pressure in the epi- 



264 DISEASES OF THE STOMACH. 

gastric and left iliac regions. There was no distention or tym- 
panites. Respiration was almost wholly thoracic. Palpation 
revealed nothing but the seat of tenderness. The pain was 
described as commencing to the left of the median line under the 
costal border, and extending thence to the left groin and into the 
left thigh. Appendicitis was out of the question, and the symp- 
toms did not appear to be those of any form of intestinal obstruc- 
tion. The diagnosis of perforated gastric ulcer was made, and 
an immediate operation advised. Dr. Weir kindly consented to 
admit the patient to his service at the New York Hospital, where 
he performed laparotomy, and sutured the stomach at 9:30 p.m., 
a little over eleven hours after the onset of the attack. 

" Under chloroform, a median incision four and one-half inches 
long was made above the umbilicus. An unusual amount of 
subperitoneal fat obscured the peritoneum. When its cavity was 
opened the stomach presented in the wound. The greater 
curvature appeared normal. There was no general peritonitis. 
The anterior surface of the stomach was adherent to the liver 
by recent lymph. As it was separated, a hissing sound w T as 
heard, due to the escape of gas from the stomach through the 
perforation. 

"The opening was found without difficulty. It was minute, 
less than one-fourth inch in diameter, with necrotic edges, and 
lying in the centre of a dense ring of inflammatory and fibrinous 
tissue, which involved the wiiole thickness of the wall of the 
stomach. This thickened area was about two inches long and 
one inch wide, and was situated in the anterior wall of the 
stomach, about midway between the greater and lesser curva- 
tures, and perhaps one-third of the distance from the pyloric 
to the cardiac orifice. 

"The operation lasted about one hour, and the patient left 
the table in fair condition, with a pulse of 150. For two days 
there was frequent and very distressing vomiting, temporarily 
relieved by gentle lavage with diluted Thiersch's solution. After 
the second day the vomiting subsided, and water was allowed by 
the mouth. Fluid nourishment was given on the third day, and 
the nutrient and stimulant enemata, which had been given every 
six hours following the operation, were stopped in four days. 
There were at no time any signs of general peritonitis. Recovery 
was otherwise uneventful." 



ULCER OF THE STOMACH. 



265 



In his exhaustive paper, AYeir gives a table, containing 
seventy-two cases of laparotomy for acute perforation of 
gastric ulcer. Among the names of operators in America we 
notice F. Markoe, Robert F. Weir, C. P. Parker, McCosh, 
Kirkpatrick, Armstrong, and Stimson. 

With regard to the results of operative treatment Weir 
furnishes the following table, which clearly illustrates the 
importance of early surgical interference: 



Elapsed time. 


Recovery. 


Death. 


Mortality 
per cent. 


Under twelve hours 


14 

4 
4 

1 


9 
13 

28 
5 


39 


Twelve to twenty-four hours. . . 

Over twenty-four hours 

Not stated 


76 
87 






Total 


23 


55 


71 



The operations above mentioned for the treatment of a 
perforating gastric ulcer will also prove applicable for a per- 
forating ulcer of the duodenum. A successful case of operation 
in the latter instance has recently been reported by A. Landerer 
and G. Gliicksmann. 1 

Surgical procedures have also lately been advised for the 
treatment of very obstinate cases of gastric ulcer, consisting 
in excision of the latter or in the establishment of a gastro- 
enterostomy. Severe, persistent pains due to the formation 
of adhesions as sequelae of gastric ulcer have also been relieved 
surgically by separating them (Lauenstein). 2 

The indications for any surgical treatment of gastric ulcer 
can be briefly summarized as follows: 

1. In large, recurrent gastric hemorrhages threatening life, 

'A. Landerer und G. GlQcksmann: " Mittheilungen aus den Grenzge- 
bieten der Medizin und Chirurgie," Bd. i., p. 108. Jena, 1896. 
2 Lauen.stein: Arch. f. klin. Chirurgie, vol. xlv. 



266 DISEASES OF THE STOMACH. 

the ulcer ought to be excised in the interval or a gastroenter- 
ostomy established, to prevent renewed hemorrhage. 2. 
Small losses of blood that cannot be checked and endanger life 
through their persistence require similar treatment. 3. Per- 
foration of the ulcer demands always immediate operation 
(excision or invagination of the defect and suture) as soon as 
the diagnosis has been made. 4. An ulcer situated at the 
pylorus and attended with peristaltic restlessness of the stom- 
ach and continuous hypersecretion, and 5. Advanced stenosis 
of the pylorus require gastroenterostomy. 6. Duodenal ulcers 
accompanied by pylorospasm and beginning peristaltic rest- 
lessness of the stomach, also, 7. Gastric ulcers with formation 
of a tumor no matter where the seat (pylorus, small curvature, 
etc.) always demand gastroenterostomy, usually with excision 
of .the tumor. If this tumor is situated in the lesser curvature 
and cannot be resected, it is still curable in case it is caused by 
simple connective tissue proliferation (callous ulcer formation). 
If we follow strict indications in operations for ulcer of the 
stomach, they are usually attended with favorable results and 
benefit for the future of the patient. 



CHAPTER VII. 

ORGANIC DISEASES WITH CONSTANT 
LESIONS. — Continued. 

Erosions of the Stomach. 

Definition. — A condition in winch the gastric mucous mem- 
brane becomes the seat of small superficial exfoliations. 

General Remarks. — As is well known, the term "erosion" 
signifies a defect of superficial nature. In the stomach erosions 
are often found at the autopsy. Of late several valuable papers 
on the pathological anatomy of this subject and on the rare 
occurrence of erosions associated with typical ulcers of the 
stomach have been published. 

In his excellent article, "Ueber geschwurige Processe im 
Magen," D. Gerhardt 1 describes erosions of the stomach in the 
following words: "Sections made of erosions as a rule show 
that at the base of the ulcerations almost the entire lower half 
of the mucous membrane is still preserved. In the epithelium 
of these remaining glands nothing remarkable can be discovered; 
at the sides the glands become longer; the first ones that are 
intact usually curve themselves over the defect and partly 
cover it. The recovery seems to take place by the simple after- 
growth of the gland remnants." 

While the subject in question has been thoroughly discussed 
and studied in respect to the pathological anatomy by Gerhardt, 
Yirchow, 2 Langerhans, 3 Harttung, 4 and Ewald, 5 very little has 

1 D. Gerhardt: Virchow'a Archiv, Bd. 127, p. 85. 
- R. Virchow: Virchow'a Archiv. Bd. 5, p. 363. 

3 B. Langerhans: Virchow'a Archiv. Bd. 121. p. ."-573. 

4 0. Harttung: Deutsche med. Wochenschr., 1800, NO. 38, p. 847. 
5 C. A. Ewald: "Diseases of the Stomach." p. 236, 1892. 

267 



268 DISEASES OF THE STOMACH. 

been done clinically. Although erosions of the mucous mem- 
brane of the stomach are mentioned in some text-books, there 
is nowhere defined how these conditions may be recognized 
during life. 

In the Medical Record of June 23d, 1894, I 1 have published an 
article which embodied observations on seven patients in whom 
small particles of gastric mucous membrane were frequently 
found in the wash water of the stomach. These cases resem- 
bled each other in so many respects that they appeared as if 
belonging to one disease. They could best be considered as 
erosions of the gastric mucous membrane. 

The description of "erosions of the stomach" w T hich I shall 
give in the following is based on the paper just mentioned. 

Within the last few years quite a number of authors have 
written on the same subject. Thus Nauwerk, 2 Pariser, 5 * 
Sansoni, 4 Quintard, 5 and Mintz 6 have published cases of hem- 
orrhagic erosions of the stomach, and have on the whole cor- 
roborated my statements. Mintz suggested the name of "Ein- 
horn's Disease" for this affection. 

Etiology. — In the vast majority of cases chronic gastric 
catarrh is probably the cause of the origin of the erosions. In 
some instances the erosions may, how r ever, be due to some 
factors yet unknown. 

Symptomatology. — The subjective symptoms are especially 
pronounced and consist of pain, emaciation, and a feeling of 
weakness. 

The pains, which are not usually intense, occur immediately 



1 See also Max Einhorn: "Further Remarks on Erosions of the Stomach." 
The Journal of the American Medical Association, May 20th, 1899. 
2 Xau\verk: Munchener med. Wochenschr., 1897, Nos. 35, 36. 
3 C. Pariser: Berl. klin. Wochenschr., 1900, Xo. 43. 

4 L. Sansoni: Arch. f. Verdauungskrankheiten, 1900. 

5 E. Quintard: Arch. f. Verdauungskrankheiten, 1901. 

6 S. Mintz: " Ueber haemorrhagische Erosionen des Magens." Zeitschr. 
f. klin. Medicin, Bd. 46, p. 115, 1902. 



EROSIONS OF THE STOMACH. 269 

after meals, independent of the character of the food of which 
the patient has partaken. They persist for a variable period of 
time (one to two horns) and disappear gradually. We have 
never observed cases characterized by severe attacks of pain. 
Intervals of complete freedom from pain of variable duration 
occur, during which the patient is perfectly well. In rare 
instances the pains are constant and independent of the 
ingestion of food. 

Emaciation. — Most cases lose in flesh during the first period 
of their sickness, but thereafter keep up their weight quite 
constantly. They look rather thin in the face (the jaws pro- 
trude, the cheeks are thin and somewhat hollow), but do not 
present that cachectic color we are accustomed to meet in car- 
cinoma and other grave chronic troubles. 

Feeling of Weakness. — All patients complain of a feeling of 
lassitude, weakness, lack of ambition, and inability to work, 
and of a decrease of bodily strength. These symptoms appear 
most markedly right after meals, and decrease somewhat a 
little while afterward (one-half to one hour). In one of my 

patients (G. B ) there usually appeared, once in a week or 

in a fortnight, an exacerbation of these symptoms associated 
with complete anorexia, which lasted for about two days. 
During this period of deterioration the patient was hardly able 
to walk. 

Objectively the following point is of the greatest importance: 
in washing the stomach, when the patient is in the fasting 
condition, one to four small pieces of gastric mucous membrane 
are found. They are about 0.3 to 0.4 cm. long and nearly as 
wide, and present a blood-red color. Under the microscope 
one sees well-preserved glands and accumulations of red blood 
corpuscles (see Fig. 79). These pieces of gastric mucosa are 
constantly found if the stomach of the patient is washed out 
in the fasting condition. We have not to deal here with an 
incidental lesion caused by the tube, for while, on the one hand, 



270 DISEASES OF THE STOMACH. 

this sign is present oven if the lavage is performed without any 
aspiration and by means of a soft tube, on the other hand, one 
could not observe in a casual lesion that constancy which is 
found here. 

In most cases blood is never found in the wash water carrying 
the small pieces of mucous membrane. Only rarely has the 
wash water a very faint red color; this occurs especially if 
coughing spells frequently appear during lavage. Besides 
containing the pieces of gastric mucosa, the water is then 
stained slightly red. 




Fig. 79. — A Piece of Gastric Mucosa (patient M. G.), showing the glands mostly vertically 
cut, and accumulations of red blood corpuscles on the lower right-hand corner. 

The pieces of gastric mucosa which are found in the wash 
water of these patients probably partly or wholly peel off 
from the mucous membrane of the stomach some time previous 
to the washing. This would explain why there is no bleeding 
during the lavage. The spots on which the exfoliations take place 
and which thus present "erosions," may explain the soreness 
mel with in these patients. One can also easily understand 
the appearance of blood from the sore spots caused by violent 
contractions of the stomach during a coughing spell. 

It is very difficult at present to decide whether the exfolia- 



EROSIONS OF THE STOMACH. 271 

tions always take place at the same spots — the mucous mem- 
brane constantly becoming replaced and peeling off — or whether 
the whole (or a great part) of the inner surface of the stomach 
is affected to such an extent that small pieces of mucosa easily 
peel off here and there. This question can only be answered 
after a long study of vast clinical and pathologico-anatomical 
material. These exfoliations take place (whether always on the 
same or on different spots) day by day in the stomach of our 
patients, and effect temporary erosions. 

Condition of the Gastric Juice. — In most cases one encounters 
a decrease in the HC1 secretion and in the acidity of the stomach 
contents. In some there is always found a considerable 
amount of mucus. Occasionally, however, there is found 
superacidity caused by an increased HC1 secretion. 

Course. — The course of this pathological condition is a very 
prolonged one. Several of the patients appear to suffer from 
it for many years. Although there may be intervals of perfect 
euphoria (at the same time probably the inner layer of the 
stomach is completely intact) for a longer or shorter period of 
time, the old symptoms do, however, sooner or later return. 

One would imagine that cases of erosions of the stomach 
would present a very fruitful soil for the development of ulcers. 
This, however, does not seem to be the case, for in none of the 
patients was there any justifiable supposition of an existing 
ulcer during the long course of the sickness. 

A- typical cases of this affection we mention the two following 

5B I. — February 11th, 1893. — H. S , aged 35, merchant, 

suffers for two to three years from digestive troubles. These 

principally in the appearance of pains right after meals; 

the pains are not severe; they produce, however, the effect that 

patient eats less. There is a feeling of fulness; bowels consti- 

1. Patient always feels weak and tired. 

The examination reveals: chest organs intact; the gastric 



272 DISEASES OF THE STOMACH. 

region is sensitive to pressure; there is splashing sound extending 
two fingers' width below the navel; right kidney movable. 

The examination of the stomach contents one hour after 
Ewald's test breakfast showed: HC1 + ; acidity = 60. 

February 13th. — When fasting, stomach empty. Lavage: 
in the wash water three small red pieces of mucous membrane 
are found. Spray with silver nitrate. 

February 14th. — Intragastric galvanization. 

February 15th. — Lavage: in the wash water three small red 
pieces of mucous membrane appear. A fresh microscopic 
specimen shows gastric glands. Spray with silver nitrate. 

February 16th. — Patient feels better — i.e., he is stronger, can 
eat more, and is not troubled with pains. Direct galvanization 
of the stomach. 

February 17th. — Lavage: no pieces of mucous membrane are 
found. Spray with silver nitrate. 

February 18th. — Intragastric galvanization. 

February 19th. — Lavage: no pieces of mucous membrane. 
Spray w r ith silver nitrate. 

February 20th. — Intragastric galvanization. 

February 21st. — Examination of the stomach contents one 
hour after the test breakfast: HC1 + ; acidity = 54; no pieces of 
mucous membrane. 

February 22d. — Direct galvanization of the stomach. 

February 23d. — Lavage: no pieces of mucous membrane. 
Spray with silver nitrate. 

February 24th. — Intragastric galvanization. Patient had to 
return to his native city, Chicago, on account of urgent business. 
As I have recently heard, patient felt well all the time with but 
few intervals. 

Case II.— April 19th, 1893.— B. M. S , aged 26, mer- 
chant, complains for two and a half years of digestive troubles. 
At first patient had lack of appetite, pains after meals, and 
nausea, but no vomiting. Feeling of weariness and fatigue; 
constipation. After some continued treatment and a trip to the 
South the condition of the patient improved for a while; soon, 
however, it got worse again. During the last tw r o years patient 
has constantly pains right after meals, with but very few excep- 
tions, and feels very weak. When fasting, patient as a rule 
feels well. 



EROSIONS OF THE STOMACH. 273 

Status prcesens. — Chest organs intact; the gastric region is 
sensitive to pressure. After drinking half a glassful of water a 
splashing sound can be produced, extending to one to two fingers' 
width above the navel. Liver not enlarged. Urine contains 
neither sugar nor albumin. 

April 20th. — Examination of the stomach contents one hour 
after Ewald's test breakfast shows: HC1 + ; acidity = 60; admix- 
ture of much mucus. 

Diagnosis. — Gastritis glandularis chronica mucosa. 

April 21st. — AVlien fasting, stomach empty. Lavage: in the 
wash water, three red pieces of gastric mucous membrane. (A 
fresh specimen in glycerin shows gastric glands.) Spray with 
silver nitrate. 

April 23d. — Intragastric galvanization. 

April 25th. — Lavage: three red pieces of mucous membrane 
appear in the wash water. Spray with silver nitrate. 

April 27th and 29th. — Direct galvanization of the stomach. 
Patient had to leave Xew York on account of business and 
returned on May 17th. 

May 18th. — When fasting, stomach empty. Lavage: three 
red pieces of mucous membrane are found in the wash water. 
Spray with silver nitrate. 

May 20th. — Intragastric galvanization. 

May 22d. — Lavage: two red pieces of mucous membrane are 
found. Spray with silver nitrate. 

May 24th. — Patient feels better, has a better appetite, and 
hardly any pain. Lavage: no pieces of mucous membrane are 
found. Spray with silver nitrate. 

May 26th. — Direct galvanization of the stomach. 

May 30th. — Lavage: no pieces of mucous membrane. Spray 
with silver nitrate. 

June 2d. — Intragastric galvanization. Patient feels well and 
is, therefore, for the present dismissed. 

Diagnosis. — The diagnosis of erosions of the stomach is made 
if the above-described subjective symptoms exist and particles 
of gastric mucosa are frequently found in the wash water when 
applying lavage in the fasting condition of the patient. 

Treatment. — The local treatment of the stomach here plays a 
18 



274 DISEASES OF THE STOMACH. 

great role. The astringent effect of nitrate of silver solutions 
in similar more accessible affections led me to apply this sub- 
stance directly to the interior of the stomach. This can best 
be achieved by means of the spray. It was on this occasion 
that I constructed the gastric spray apparatus (see Fig. 62, 
p. 164), and recommended its use in the field of diseases of the 
stomach. 1 

In fact, the good result of this method of treatment can fre- 
quently be best shown in the affection in question, for after 
the spraying has been done several times the small pieces of 
gastric mucosa cease to appear. Associated with this objective 
symptom there appears an amelioration in the subjective feeling 
of the patient; the pains grow considerably less or entirely 
disappear, and the strength increases. 

The treatment is given in the following way: First, the 
stomach in a fasting condition is washed out with lukewarm 
water; when all the water has been emptied, the tube is 
removed from the stomach. The spray apparatus is filled 
with 10 c.c. of a . 1 to . 2 per cent, solution of nitrate of silver, 
the tube end dipped into warm water and inserted into the 
stomach (length of tubing 50 cm.); thereupon the whole, or 
at least the greater part, of the solution in the bottle is sprayed; 
the bottle is then opened and the spray tube removed from the 
stomach. 

I usually combine the nitrate-of-silver spray treatment with 
intragastric galvanization, alternately applying the spray or the 
galvanization. The reason for the use of galvanization in these 
cases lies in the fact that I had such effective results in two 
other cases of probable erosions of the stomach, complicated 
with heart trouble, 2 by means of galvanization alone. The 
methodical application of intragastric glavanization combined 
with the spray seems to increase the curative effect. 

1 M. Einhorn: New York Medical Journal, September, 1892. 

2 Max Einhorn: New York Medical Journal, July 8th, 1893. 



EROSIONS OF THE STOMACH. 275 

Recently I have used the extract of suprarenal gland (Armour 
& Co.) — powdering the stomach in the fasting condition, 
every other day, with about three grains (instead of the 
nitrate of silver spray) — also with very good results. 

In some instances in which the just described local treatment 
is not feasible, large doses of subnitrate of bismuth (5ss. t. i. d., 
half an hour before meals) ma} 7 be given with advantage. 

As to diet, there is no need for being very rigorous in these 
cases. Frequent meals, avoiding heavy vegetables, salads, and 
pastries, is all I ordinarily require. 

Cold ablutions, light gymnastics, outdoor life are to be 
warmly recommended. 

Of medicaments condurango and nux vomica are frequently, 
and a good, easily assimilated iron preparation is always, 
appropriate. 

Although these medicaments may be of value as adjuvants, 
we should rely, in my opinion, mainly upon the local treatment. 



CHAPTER VIII. 

ORGANIC DISEASES WITH CONSTANT 
LESIONS.— Continued. 

Cancer of the Stomach (Carcinoma Ventriculi). 

Definition. — Malignant epithelial growth within the stomach. 

Etiology. — The stomach is more frequently affected with 
cancer than any other organ of the body. Virchow's 1 statistics 
of all the cancerous diseases which occurred in Wurzburg 
between 1852 and 1855 give for the stomach the proportion of 
34.9 per cent. According to Lebert, 2 Willigk, 3 and Brinton, 4 
cancer of the stomach comprises about one-fourth of all cases 
of cancer. Haeberlin 5 found the percentage of cancer of the 
stomach for the years from 1877 to 1886 to be 41. According 
to Wyss, 6 the death-rate from this disease is 1.9 per cent. 
This figure, however, is liable to many fluctuations. Haeber- 
lin first pointed out the very curious and discouraging fact 
that the frequency of gastric cancer is steadily increasing. 
This writer's statistics for Switzerland show a death-rate from 
-cancer of the stomach for 1,000 inhabitants in the years: 
1877,0.61; 1878,0.66; 1879,0.72; 1880,0.77; 1881,0.85; 
1882,0.87; 1883,0.85; 1884,0.84; 1885,0.90; 1886,0.99. 

Joseph D. Bryant, 7 of New York, has also shown that 
cancerous disease is constantly on the increase. According to 

1 Virchow: Cited from Debove et Remond, I. c, p. 297. 

2 Lebert: "Traite pratique des maladies cancereuses," Paris, 1851, p. 97. 

3 Willigk: Prager Vierteljahresschrift, vol. x., 2, 1853. 

4 W. Brinton: British and Foreign Medico-Chirurg. Review, January, 1857. 

5 Haeberlin: Deutsch. Arch. f. klin. Medicin, 1889, Heft 3 und 4, p. 461. 
G Wyss: Blatter f. Gesundheitspflege, Zurich, 1872-74. 

7 Joseph D. Bryant: The Wesley M. Carpenter Lecture. New York 
Medical Journal, May 18th, 1895. 

276 



CAXCER OF THE STOMACH. 



277 



this eminent writer, the average death-rate from cancer in New 
York City during the last ten years is 2 . 17 per cent, of the total 
mortality, but that of the preceding ten years only 1.82 per 
cent. The following table, given by Dr. Bryant, is very 
instructive as bearing on the increase of cancer in the United 
States: 











Cancer 


Cancer 






Total 


Deaths 


deaths per 


deaths 


Year. 


Population. 


deaths. 


from 


100,000 from 


per 100,000 








cancer. 


all causes. 


living. 


1850 . . . 


23,191,876 


323,023 


2,088 


646 


9.0 


1860 . . . 


31,443,321 


394,153 


3,672 


932 


11.7 


1870 . . . 


38,558,371 


492,263 


6,224 


1,264 


16.0 


1880 . . . 


50.155,783 


756,893 


13,068 


1,815 


26.05 


1890 . . . 


62,622,250 


875,521 


20,984 




33.5 



The frequency of gastric cancer appears to be different in 
different countries, and it seems that there are some regions 
in which it very seldom occurs. Haeberlin's above-mentioned 
statistics for the whole of Switzerland show a death-rate from 
cancer of the stomach of 3 per cent, for the northern 
cantons, 1.5 per cent, for the western cantons, and 1 per 
cent, for the southern cantons. Griesinger 1 states that he 
never observed cancer of the stomach in Egypt, and Heine- 
mann 2 reports that he saw only one case in Vera Cruz in a period 
of six years. 

Age. — As regards the age at which gastric cancer occurs, 

Brinton collected GOO cases, the ages of which at death averaged 

50 years. The greater part (three-quarters, or 435) of these 600 

fell in the epoch of life between 40 and 70. Arranged in 

decades of years, the maximum number (two-sevenths, or 162) 

: Griesinger: Arch. f. phys. Heilkunde, 1854, p. 528. 
2 Heinemann: Vireh. Arch., vol. 58, p. 180. 



27S DISEASES OF THE STOMACH. 

occurred between 50 and GO. Comparing these numbers with 
the number of persons living in these decades of life, an estimate 
of the relative liability of the corresponding ages to the malady 
is obtained. Brinton gives the maximum liability between 60 
and 70. Up to the age of 20, the whole risk is less than one- 
fiftieth of what it reaches between 20 and 30. The latter lia- 
bility is multiplied in the following decades of years by 3, 6, 8, 
and 10 respectively. The maximum then seems to sink to 
little more than half for the next two decades, ending at the 
extreme age of 100. With reference to age, Lebert gives the 
following figures in his statistics: Under 30 years, 1 per 
cent.; 30 to 40 years, 17.6 per cent.; 40 to 60, 60.7 per cent.; 
60 to 70, 16.3 per cent.; above 70, 4.4 per cent. Welch's 
statistics of 2,075 cases of gastric cancer show the following 
distribution for the different ages: 10 to 20, 2; 20 to 30, 55; 
30 to 40, 271; 40 to 50, 499; 50 to 60, 620; 60 to 70, 428; 
70 to 80, 140. 

According to all these statistics, the maximum liability of 
gastric cancer lies between the fortieth and sixtieth year. It is 
very rare before the thirtieth year. Both Wilkinson and 
Wiederhoefer, 1 however, each mention a case in which the dis- 
ease was congenital. M. Mathieu 2 has collected all the cases of 
gastric cancer below the thirtieth year mentioned in literature, 
and the number was 27. Debove 3 recently published a case 
of gastric cancer in a young man of 24 years, and I observed a 
similar case in a man of 27 years some years ago. In this latter 
case the disease was verified by an operation. 

Sex. — The influence of sex is far more difficult to estimate 
than that of age. Brinton mentions 784 cases, of which 440 
were males and 344 females. Fox's 4 tabulation of the state- 
ments of seven writers shows that of 1,303 cases 680 were 

1 Cited from Eichhorst: "Lehrbuch der spec. Path, und Therapie." 

2 Max Mathieu: Gaz. des Hopit., 1884, p. 118. 

3 Debove: Soctete' med. des hopit., November, 1889. 

4 Fox: "The Diseases of the Stomach," London, 1872, p. 184. 



CAXCER OF THE STOMACH. 279 

males and 623 females. Of Welch's 2,214 cases, 1,233 were 
men and 9S1 women. 

These figures show a higher percentage for men than women, 
but this statement is not of necessity absolutely true, for the 
larger percentage of cancer among men may result from the 
larger number of male patients treated in the hospitals from 
which these statistics have been obtained. 

Heredity. — Most writers concur that in some families several 
members are found to be afflicted with cancer, and are inclined 
to attribute this fact to heredity. Every physician has observed 
cases in which the father and one or two sons had been 
troubled with cancer. In some instances there is a history of 
cancer in the parents, relating perhaps to some organ other 
than the stomach. Cancer being such a frequent malady, 
however, it is quite difficult to state whether these occasionally 
observed facts are sufficient to prove that heredity plays an 
important part, or whether it is a mere coincidence. Statistical 
figures on this point are given by Lebert and Haeberlin. The 
former found an hereditary history in 7, the latter in 8 per cent. 
Snow found among 1,075 cases of cancer in different parts of the 
body, 176 cases, or 15.7 per cent., in which cancerous disease 
had existed in the family. 

Cause. — Many factors have been regarded as playing an 
important part in the origin of cancer. Thus a trauma in the 
gastric region has frequently been held responsible for a can- 
cerous affection. There is no doubt but that cases occur in 
which a few weeks previous to the discovery of a tumor in the 
abdomen a trauma in the affected region had taken place. 
But it would certainly be wrong in all these cases to attribute 
the neoplasm to the preceding trauma; for there are certainly 
some cases in which the neoplasm already existed before the 
trauma occurred, and in which the latter merely caused the 
at to pay more attention to the injured region, and in this 
way led to an earlier recognition of the tumor. The frequent 



2S0 DISEASES OF THE STOMACH. 

use of cider and of sour wines is said (Eichhorst and Colquet) 
to favor the formation of a cancer. Mental worry and sad 
emotions have, probably wrongly, been regarded as playing a 
part in the causation of this affection. 

Brinton suggested the following explanation for cancer of 
the cardia and pylorus: The muscular fibres of these two orifices 
are subjected to more work (contraction) than the rest of the 
stomach. The connective tissue enclosed in them is subject 
to contraction and distention. All this causes a more vivid 
nutrition of these parts, and may give rise to proliferation of 
the glandular tissue, forming a neoplasm. 

Inflammatory conditions of the gastric mucous membrane 
have frequently been described as a predisposing factor of the 
disease. Menetrier 1 tried to show the connection between 
some forms of chronic gastritis (polypi) and the cancer. I 
must, however, agree with Ewald and Rosenheim that there is 
no reason to believe that a chronic gastritis favors the develop- 
ment of cancer, for in most instances we can state that the 
cancerous trouble developed more or less suddenly without any 
preceding history of a long-standing dyspeptic trouble. The 
gastritis found at the autopsy in cases of gastric cancer is rather 
a secondary or accompanying condition than a primary factor 
in the disease. Chronic gastric ulcers undoubtedly belong to 
the predisposing factors. Several cases have been described 
in which the formation of a cancer on the border of a gastric 
ulcer or its scar could be clearly seen. Thus Hauser 2 has histo- 
logically demonstrated the transition of ulceration into car- 
cinomatous proliferation, and asserts that in one of the cases 
examined by him he found not only the secondary development 
of carcinoma in a gastric ulcer of very long standing, but that 
occasionally a cancer may develop from an affection of the 
gastric glands. 

1 Menetrier: Arch, de physiolog., 15 fevr., 1888. 

2 Hauser: "Das chronische Magengeschwiir und dessen Beziehung zur 
Entwickelung des Magencarcinoms," Leipzig, 1883. 



CAXCER OF THE STOMACH. 281 

Parasitic Theory. — All the etiological factors mentioned may 
perhaps give ns a better understanding of the development of 
the carcinoma, but do not by any means explain the ultimate 
cause of this malignant affection. Of late the parasitic theory 
of infectious diseases has furthered the belief that in cancer also 
we may have to deal with some micro-organism. Many recent 
investigators have made numerous studies and experiments in 
order to elucidate this matter. Scheuerlen 1 believed he had 
discovered a bacillus, to which he ascribed the origin of cancer. 
Later researches, however, have demonstrated that his asser- 
tions were wrong. Coley, 2 of Xew York, and Emmerich, 3 of 
Munich, have seen good results in the treatment of sarcoma, 
and also carcinoma, from the use of injections of the blood 
serum of horses which had been treated by the erysipelas cocci. 
This fact speaks in favor of a parasitic origin of this malignant 
growth. Psorosperms have frequently been found within the 
cancer cells. Thus Bra 4 asserts to have found the parasite of 
cancer, which is a coccidium. It is, however, not as yet- 
determined whether these bodies are real psorosperms or dried- 
up and changed cells. Hence we must confess that, notwith- 
standing the many researches into the pathology of cancer, we 
are as yet totally ignorant of its origin. 

Morbid Anatomy. — It was first established by the researches 
of Waldeyer 8 that the cancerous process originates from the 
glandular elements of the mucous membrane, its character 
being chiefly an atypical proliferation of the gastric follicles. 
Hence the origin of the neoplasm is in the mucosa, whence it 
penetrates the submucosa, forming here a more or less large 
deposit. Frequently the larger part of the growth is situated 

Scheuerlen: "Verhandl. des Ver. f. inncro Medicin." Deutsche mecL 
Wochenschr., 1887, No. 48. 

"Coley: American Journal of the Medical Sciences, 1894. 

Emmerich: Deutsche med. Wochenschrift, 1895. 
4 Bra: Presse m&i., February 22d, L899. 

Waldeyer: Virch. Arch., Bd. lv., p. 54. 



282 DISEASES OF THE STOMACH. 

beneath the mucosa. After a while this malignant infiltration 
may attack the muscularis, and thereafter extend to the serosa. 
The spread of the infiltration, as a rule, takes place along the 
connective-tissue fibres. The neoplasm, after having reached a 
certain degree of development, may partly slough, thereby 
giving rise to irregular, ulcerated spots. This occurrence is 
most frequent in certain forms of cancer. 

Cancer of the stomach, like that of other organs, may present 
the following varieties: 

1. Epithelioma. — The adeno-carcinoma or epithelioma forms 
soft tumors, presenting quite marked nodules and sloughing 
very slowly. It consists of pseudo-glandular tubuli, surrounded 
by connective tissue and infiltrated with white blood corpuscles. 
These nodules show no regularity and have no outlets. 

In the early stage the cylindrical epithelium is distinguish- 
able, but as the growth gets older the regular arrangement of 
the epithelium is lost and the tubular spaces become filled with 
cells, the product of the multiplication of the epithelial cells. 
The latter undergo various forms of degeneration, and may- 
form small cysts containing granular material and liquid. 

2. Medullary Carcinoma. — The medullary carcinoma is char- 
acterized by large, flat, soft, f ungating masses, projecting above 
the mucuos membrane. The growth possesses very' little con- 
nective-tissue stroma, but is rich in vessels and cells. It is 
spongy and presents on section a whitish-yellow color, resem- 
bling brain matter in color and consistence. This form of 
growth is liable to produce frequent hemmorrhages (in case the 
tumor looks blackish in consequence of blood pigment, it is 
called "melanotic"); and very often degenerates, forming ulcer- 
ous spots on the surface. Secondary metastases are very 
frequent complications. 

3. Sdrrhus (carcinoma simplex or fibrosum). — The scirrhus 
is characterized by the abundance of connective tissue. The 
stroma is encircled by dense connective-tissue fibres, and con- 



CANCER OF THE STOMACH. 283 

tains relatively few cells. The growth has a firm and compact 
structure. It does not cut easily, and on section presents an 
almost cartilaginous tissue of a white-grayish yellow color, 
with yellow or red spots scattered all around. This growth 
shows little tendency to ulceration in its early stages, but when 
older it is frequently found superficially ulcerated. There is but 
little tendency to secondary metastasis. 

4. Colloid Carcinoma. — The cells of the alveoli of the first- 
described two forms of cancer may undergo a colloid or mucous 
degeneration. The whole growth then assumes a gelatinous 




Fig. SO. — Section of Carcinoma Ventriculi (Mrs J.), scirrhus form. X140. 

appearance. Thus arises the colloid carcinoma. Its appear- 
ance is very characteristic: the stroma of the tumor surrounds 
transparent, gelatinous-looking masses, which consist of the 
cancer cells in a condition of colloid degeneration. On cutting 
and scraping, a true cancer juice does not exude, but, instead, 
gelatinous fragments. 

The above-described forms of cancer are not always 
typically characterized, but different forms may sometimes 
iiind in one and the same growth. At times, again, the 
form of the growth changes from one to the other of the just- 
named varieties of cancer. The scirrhus is by far the most 



284 



DISEASES OF THE STOMACH. 



common. Out of 180 cases of cancer Brinton found 130 be- 
longing to this variety (72 per cent.); 32 were medullary 
cancer, 14 colloid, 3 melanotic, and 1 epithelioma. 

Topographical Relations of Cancer of the Stomach. — Size. — 
As regards size, two varieties of tumors may be distinguished. 
One is characterized by growing very little above the surface 
and involving large areas of mucous membrane. The other 
extends only over a small portion of the mucosa, and may 




Fig. 81. 



«\fc. 



-Cross-Section of Carcinoma Ventriculi (S.), showing cancer cells infiltrating the 
connective tissue. Small area of inflammation in centre. X 140. 



develop extensively in thickness. The first form of tumors 
belongs to the medullary or colloid type, and is not met with 
very frequently. These growths present a flattened surface, 
covered with rough, nodular masses. Blood extravasations 
and adhesions to the neighboring organs are of frequent occur- 
rence. The second form belongs to the scirrhus variety. The 
tumor involves a small circumscribed portion of the stomach, 
and tends to grow in depth and height. 

Localization. — The development of cancer within the stomach 



CANCER OF THE STOMACH. 285 

may take place at various situations, at its orifices (cardia or 
pylorus), or within the organ itself. The recognition of the 
localization of the cancer is much more important than the 
distinction of the various forms, because each of the three 
different localizations of the cancer is accompanied by a char- 
acteristic train of symptoms, making its recognition possible 
during life, and requiring a special plan of treatment. As 
regards the frequency with which the different regions of the 
stomach are affected by cancer, Brint on found the following 
relation: Out of 360 cases the pylorus was affected in 219 
instances, a proportion of exactly 60 per cent.; 36 cases 
were cancer of the cardia, a proportion amounting to exactly 
10 per cent.; in the remaining 30 per cent, the lesion was 
scattered over the greater and lesser curvatures. The fundus 
is attacked least frequently of all: among 1,300 cases of cancer 
of the stomach reported by Welch, only 19 were situated in 
the fundus. The figures given by Lebert, 1 Katzenellenbogen, 2 
and other writers, agree very closely with Brinton's figures. 
It is easily seen that the localization of the cancer is very 
markedly different from that of ulcer, for in the latter affection 
the orifices of the stomach are the least frequently affected. 

The Shape of the Stomach. — The different situations of the 
cancer influence the shape and the position of the stomach. 
The organ is found to be retracted and small in size in all cases 
of cancer of the oesophagus and cardia. The viscus is very much 
dilated in cases of cancer of the pylorus. The shape of the 
stomach may be distorted in case the tumor, situated near the 
pyloric orifice, descends by reason of its weight and drags the 
organ down into the pelvis. Distortions and contractions of 
-omach may also be developed as a consequence of in- 
flammatory adhesions with adjacent viscera. 

1 Lebert: "Traite pratique de.s maladies cancereuses," Paris, 1851, p. 97. 
'Katzenellenbogen: "' Heitriige zur Statistik des Magencarcinoms." 
Inauf:. Was., Jena, 1878. 



286 DISEASES OF THE STOMACH. 

Gastric cancer is almost always primary, and secondary 
growths of the stomach must be considered as a great rarity. 
Cancer of the stomach may, however, coexist with a primary 
cancer of some other organ, as, for instance, the uterus and 
ovaries. Ewald mentions a case in winch he found an im- 
mense cystosarcoma of the uterus and a carcinomatous in- 
filtration of the pylorus. 

Secondary Changes Accompanying Cancer of the Stomach. — 
Aside from the cancerous lesions, the affected area of the 
stomach is usually the seat of various anatomical changes. 
Thus thickening of the mucosa, caused by hypertrophy of 
the connective tissue and muscular fibres, is frequently ob- 
served. Ewald first observed that the whole mucosa may 
present characteristic lesions of chronic gastritis. At some 
places the glands have disappeared; at others they exhibit 
mucoid changes; while at still others cysts are found. 

Cancerous Metastases. — Secondary cancerous deposits in 
other organs are of frequent occurrence in cancer of the 
stomach. Out of 437 cases Brinton saw this complication in 
210, or in 48 per cent. The medullary and colloid forms of 
cancer are more often associated with secondary cancer than 
is the scirrhous form. Among the organs in which the sec- 
ondary cancerous deposits appear, the liver takes the first 
place. Brinton gives the figure of secondary deposits in 
the liver as 25 per cent, of all cases of gastric cancer, while 
Lebert gives the figure of metastasis in the liver as 40.9 
per cent, of all the metastases. This writer gives the follow- 
ing figures for the metastases in other organs: peritoneum, 
37.5 per cent.; lungs, 8.3 per cent.; ovaries, 4.5 percent. 
In some cases, however, the secondary cancer of the liver is 
associated w T ith deposits in the other organs; for instance, 
the peritoneum, pancreas, kidneys. The intestines and lungs 
may be affected at the same time. The metastatic infection 
usually takes place by way of the blood current or the lymph 



CAXCER OF THE STOMACH. 287 

vessels. In some instances, however, a direct extension in 
continuity of the cancerous growth to a neighboring organ 
may take place. Thus the extension of a pyloric cancer to 
the liver or the gall bladder, or of a cancer situated at the 
greater curvature to the colon, or, again, of a cancer of the 
smaller curvature to the pylorus, is often observed. 

The lymphatic glands are frequently found swollen, but in 
cancer of the stomach this symptom does not appear as often 
as in neoplasm in other organs. Brinton has observed this 
symptom in 23.5 per cent, of these cases. The swelling of the 
glands is frequently caused by cancerous deposits in them; 
sometimes, however, they may be swollen simply in conse- 
quence of a condition of irritation. The cancerous de- 
posits may appear at one spot, forming a new tumor vary- 
ing in size in the respective organs; sometimes, especially 
if the cancerous material has been carried through the 
lymphatics, numerous small deposits may exist, and the 
whole organ may then appear as if studded with miliary 
tubercles. Tins condition is frequently found in the pleura. 
It is at first quite difficult to decide at one glance the real 
nature of this tubercle-like deposit. The microscope will 
quickly solve the problem. Koch's bacillus is found in the 
real tubercles, while the cancerous deposits contain no bacilli 
and will show the characteristic structure of the neoplasm. 
While the cancerous deposits may at times appear in this 
form, simulating a tuberculous affection, the latter condition 
may occur independently in cases of cancer of the stomach; 
that is to say, both affections, viz., cancer and tuberculosis, 
may coexist in the same person. 

nptomatology. — In a typical case the course of the disease 
follows: A person, usually of middle age, who has been 
previously in good health, experiences uncomfortable sensa- 
tions after meals, impairment of appetite, more or less dis- 
turbance of sleep, and loss of strength. Although slight at 



288 DISEASES OF THE STOMACH. 

first, those symptoms persist and remain obstinate to all 
methods of treatment. In the course of time they become 
more and more aggravated. Pains appear, which are always 
very annoying and sometimes show exacerbations of a very 
acute and intense form. While at first there is only belching 
and a mouthful of food is occasionally ejected, after a while 
vomiting appears and deprives the patient of the little nourish- 
ment he takes. Still later hemorrhages appear. Although 
the quantity of blood ejected is, as a rule, not large, this 
symptom, however, greatly debilitates the patient, as it 
usually occurs several times in succession. About the same 
time that the hemorrhage begins to appear, a tumor becomes 
perceptible in the gastric region. The patient now presents a 
cachectic appearance and falls off daily. He becomes ex- 
tremely weak and prostrated, and usually death from inanition 
follows: 

In analyzing the symptoms accompanying a neoplasm of the 
stomach, it is important to divide them into: A, Those caused 
by the growth itself (general symptoms) ; and B, those produced 
by the position of the growth — (a) cardia; (&) pylorus; (c) 
stomach proper. 

A. General Symptoms. — These are partly subjective, partly 
objective, and may be enumerated as follows: 

1. Anorexia, or loss of appetite, is a very frequent although 
not very characteristic symptom of gastric cancer. Numeric- 
ally Brinton found it present in eighty-five per cent. The 
appearance of this symptom is sometimes delayed until a com- 
paratively late period. Anorexia in this instance is not caused 
by any fear of pain the ingested food may invoke, but is at- 
tributable to a direct lesion of the nerve centre of hunger. 
There is a real loss of appetite, or no desire, no inclination to 
take food. In some instances there exists an actual aversion for 
food, especially with reference to all kinds of meat and food 
rich in albumin. Sometimes there is present in these cases a 



CAXCER OF THE STOMACH. 289 

craving for highly seasoned articles, such as pickles, herring, 
and so on. 

2. Pain. — Pain is the most constant of all symptoms. It is 
present, according to Brinton, in about ninety- two per cent., 
and according to Katzenellenbogen in a still larger percentage 
of cases. The situation of the pain does not always correspond 
to the site of the lesion. Thus a pyloric cancer may cause 
pains referable not only to the right hypochondrium, but also 
to the sternum or the left hypoehondrium. The pain most 
characteristic of this conditon is usually of a lancinating char- 
acter. It begins at a comparatively early date, and soon 
assumes a marked severity. Often it becomes so intense that 
all other symptoms are relegated to the background. It is 
characteristic of the pain of gastric cancer that it never entirely 
disappears. There may be remissions in the severity of the 
pain, but there are never really free periods. Unlike the pain 
of gastric ulcer, it is either little or not at all affected by the 
ingestion of food. Never is it relieved at the end of gastric 
digestion or after vomiting. The character of the pain is 
sometimes described by the patients as dull, gnawing, or 
burning; sometimes as being attended by a sense of weight, 
oppression, tightness, or distention in the epigastrium; some- 
times, again, by soreness or tenderness to pressure in this 
region. Exacerbations of the pains are frequently caused by 
ulcerative processes taking place on the surface of the cancer; 
sometimes, again, by inflammatory adhesive processes with the 
neighboring organs. 

3. Vomiting. — Vomiting is likewise one of the most frequent 
symptoms. Brinton found it present in eighty-seven and one- 
ninth per cent, of his cases, and Arnold in eighty-six per cent. 
The frequency of this symptom is largely dependent upon the 
situation of the cancer, occurring much oftener in those cases 
in which the cancer occupies either the pylorus or the cardia. 
But it may exist even when the cancer has no connection what- 

19 



290 DISEASES OF THE STOMACH. 

ever with the orifices of the stomach. The vomiting takes place 
either sometimes after the ingestion of food or independent of 
it. Thus some patients vomit in the morning when arising, 
and eject either a quantity of mucus or, more frequently, some 
undigested and decomposed food particles. The ejected matter 
often has an offensive smell, and as a rule contains numerous 
micro-organisms, sarcinse, yeast cells, and sometimes changed 
blood. 

4. Hemorrhage. — Vomiting of blood is observed, according to 
Brinton, in about forty-two per cent, of the cases of gastric 
cancer. The blood is sometimes ejected in sufficiently large 
quantity to be recognized with the naked eye. More fre- 
quently, however, it is not vomited in the pure state, but 
mixed with gastric juice, food, mucus; sometimes the blood 
has undergone many changes during its sojourn in the stomach, 
and then looks blackish, brownish, or presents a coffee-ground 
appearance or is not visible at all ("occult blood"). The 
quantity of blood ejected is, as a rule, smaller in gastric cancer 
than in ulcer; but while in ulcer the hemorrhage if once 
entirely arrested very seldom recurs, it is quite different in 
cancer. For here small hemorrhages appear in succession for 
a long time, at intervals of a few days' duration. Melsena 
(blood in the stool) sometimes accompanies the hemorrhage. 
It is found, however, less frequently than in gastric ulcer. 
The hemorrhage, as a rule, takes its origin from the minute 
vessels of the submucous plexuses or from the capillaries of 
the superficial layer of the mucosa covering the neoplasm. It 
is very seldom that a larger vessel is opened, and in that case 
a fatal issue results. The hemorrhage is also caused by mani- 
fold processes of ulceration, involving the vessels of the can- 
cerous mass. 

5. Tumor. — The presence of a tumor in the gastric region is 
one of the most reliable and pathognomonic signs of cancer. 
The recognition of this will depend upon its size and position. 



CANCER OF THE STOMACH. 291 

The larger the tumor, the more superficially it is situated, the 
more easily can it be detected. Inspection alone sometimes 
suffices to make us suspect a malignant growth; on looking at 
the gastric region, either in the standing or recumbent position 
of the patient, a protrusion is noticed, either below the ensi- 
form process or at the margin of the ribs on the right or left 
side. The result of inspection must always be corroborated 
by the palpation method. The latter is much more reliable 
and by far more effective. The palpating fingers encounter a 
resistant body of varied size and shape, often presenting the 
appearance of a hard, irregular, nodulated mass; sometimes, 
however, being smooth and small, and but slightly different 
from a contracted abdominal muscle. The latter cases are 
the most difficult to recognize, and sometimes a positive diag- 

sds as to the presence of a tumor can hardly be made. Per- 
cussion is another means of verifying the results of palpation. 
The presence of a tumor in the stomach will give a dull sound 
on gentle percussion, and sometimes a tympanitic note on firm 
percussion. 

In establishing the diagnosis of tumor or neoplasm of the 
stomach, it is necessary to have in mind also the existence of 
''apparent tumors" of the abdomen, 1 which may be mistaken 
for real growths. 

The apparent tumors which I speak of here relate to swellings 
found either directly in the epigastrium or the left or right hypo- 
chondrium, and have nothing to do with a neoplasm of whatever 
kind. In most cases of this kind a resistance may be detected 
by palpation, sometimes even by inspection, lying between 
the ensiform process and the umbilicus, presenting a rather 
smooth surface and frequently pulsating. The size of these 
tumefactions varies between that of a hen's egg and a man's 
fist. Light percussion always elicits a dull sound over the 

Max Einhorn: "On Apparent Tumors of the Abdomen." Medical 
i ; November 24th, 1900. 



292 DISEASES OF THE STOMACH. 

area of resistance. These apparent tumors are not exactly 
of frequent occurrence. The apparent tumor may be pro- 
duced: (1) By a prolapse of the left lobe of the liver; (2) by 
exposure and thickening of the abdominal aorta; (3) by a 
hypertrophic condition of parts of the abdominal muscles; (4) 
by adhesions (?) around the lesser curvature of the stomach. 

The left lobe of the liver may be the cause of the apparent 
tumor when it is situated in the median line directly under 
the ensiform process. Frequently we will get above the 
resistance, especially at the ensiform process, instead of liver 
dulness, a more tympanitic sound on percussion. The swell- 
ing in these cases is of considerable dimensions (size of a fist). 

If the apparent tumor is caused by the aorta, it usually lies 
deep in the abdominal cavity, close to the spinal column, has 
an elongated shape, and pulsates strongly. The resistance is 
usually one to two thumbs in diameter and about two inches 
in length. Such a tumor is often mistaken for an aneurism. 

The abdominal muscles are probably the cause of the 
tumor if it lies superficially and can be palpated to one side, 
either right or left, of the linea alba. The resistance usually 
runs horizontally and measures about one to one and a half 
inches in breadth by two to three inches in length; its surface 
is not globular like in tumors caused by the liver, but more 
flat, although it may be slightly rounded at the sides. 

Adhesion of the stomach is hard to determine with certainty. 
The resistance felt is rather indefinite, small, lying generally at 
the lesser curvature of the stomach toward the pylorus, and 
does not show the characteristic distinctions of the three 
other groups. Whether the tumor belongs to one or other of 
the four groups is of less importance than the decision of the 
question whether in a given case we have to deal with a real 
tumor (neoplasm) or only with an apparent tumor. 

I apparent tumors the swelling presents a more or less 
smooth surface; at all events there are no distinct nodules. 



CAXCER OF THE STOMACH. 293 

The tumor is not always felt with the same degree of distinct- 
ness and sometimes may escape palpation altogether. It 
occupies the position described above, and a high degree of 
enteroptosis is usually associated with it. As further aids to 
diagnosis, we have the course of the disease, which usually 
extends over years; the age (it may occur from the time of 
adolescence to old age), and the malnutrition, which generally 
is not of recent date, but has lasted for a long time. 

Whether the existing tumor belongs to the stomach or not, 
and also what region of the organ it occupies, can be determined 
by the following methods: A tumor of the lesser curvature 
moves slightly downward on deep inspiration, and becomes 
less distinct or sometimes disappears on deep expiration. On 
inflating the stomach with carbonic-acid gas or with air, the 
resistance will be found just above the gastric area. Tumors 
of the pylorus, if not adherent to the liver, will move down on 
inspiration, and if held in this position with the hand will not 
ascend during expiration; if adherent to the liver they will 
move up during the act of respiration. A tumor of the pylorus 
sometimes disappears when the stomach is full, on account of 
the different positions the stomach occupies in its empty and 
in its filled states. A tumor of the greater curvature will 
move up and down during inspiration and expiration, and 
will also descend when the stomach is inflated with air; it will 
then occupy the lowest border of the inflated area. 

According to my experience, transillumination of the stomach 
gives the best results with regard to the recognition of the pres- 
ence of tumors and the determination of their situation. The 
tumor, not being translucent, is visible as a dark spot within the 
red transilluminated zone of the abdominal wall. It appears on 
top of this zone when the tumor occupies the lesser curvature, 
and at the base of the transilluminated area when it springs 
from the greater curvature. The dark spol is ;il the right in 
tumors of the pylorus. In some instances transillumination 



294. DISEASES OF THE STOMACH. 

discloses the presence of a tumor even when the latter is not 
yet accessible to palpation. 

0. Fever. — The occurrence of fever in gastric cancer does not 
belong to the regular symptoms. It is, however, met with 
oftener than is generally believed. It usually appears in the 
latest stages of the disease, and is always a bad omen; for 
frequently the fatal issue is then impending. In rare instances 
the rise of temperature occurs at certain periods of time, and 
presents a marked similarity to a fever of malarial origin. 
Hampeln 1 relates a case presenting this peculiarity. In most 
instances the fever does not show any regularity, is, as a rule, 
not very high, and accompanied by frequent intermissions. 
The fever is probably due either to an inflammatory process 
which occurs in the neighborhood of the neoplasm, or, more 
frequently, to the absorption of toxic material from ulcerated 
areas of the tumor. The latter circumstance is also responsi- 
ble for a comatose condition which is sometimes met in these 
cases, especially in the last stages of the disease. 

7. Constipation. — More or less obstinate constipation exists 
in the majority of cases of gastric cancer. According to Ewald, 
the bowels remain regular in only four to five per cent, 
of the cases. The constipation may at times alternate with 
diarrhoea; the latter is the result of a catarrhal condition of the 
intestinal mucous membrane, due to the irritation of hard 
scybala or to the products of decomposition. Frequently 
diarrhoea appears whenever sloughing of the neoplasm occurs. 
It often indicates imminent danger, and is not unfrequently 
the proximate cause of death. 

8. Cachexia. — Cachexia is met with in almost all cases of 
gastric cancer after the disease has progressed long enough, 
and is, if present, an important symptom. Its absence, how- 
ever, by no means militates against the existence of cancer. 

1 P. Hampeln: Zeitschr. f. klin. Med., Bd. 8, p. 232. 



CAXCER OF THE STOMACH. 295 

Brinton regarded, cachexia as pathognomonic of cancer, being 
the result of a humoral disease. At present, however, most 
writers agree that the cachexia is brought about in most 
instances not by specific poisons circulating in the blood, but 
by subnutrition. From my own experience, I can state that I 
have frequently made the diagnosis of gastric cancer in people 
who presented a very healthy appearance, and who had not 
become emaciated. The diagnosis in some of these cases was 
later verified either by an operation or at the autopsy. In one 
case of cancer of the pylorus in a man, forty-two years of age, 
who had slightly lost in weight but who was yet well nourished, 
in the first few weeks of treatment an increase in weight of 
eight to ten pounds was effected. The same patient was 
operated upon some time afterward, the pylorus being resected, 
but he succumbed one year later. 

9. (Edema. — In the first stages of cancer malleolar oedema 
sometimes appears for a short time. Boas 1 found this symp- 
tom in twelve per cent, of his cases. This oedema fugax is, 
however, not a pathognomonic sign, as it may occur, according 
to Boas, in other affections of the stomach of a non-malignant 
type. Ascites or anasarca, or both, frequently appear in the 
last stages of the disease. 

10. Metastases. — As mentioned above in speaking of path- 
ology, metastatic tumors frequently occur. Thus enlarged 
glands of hard consistence and nodular character are sug- 
gestive of cancerous deposits. A nodular infiltration of the 
liver, presenting a hard and uneven surface, is very frequently 
met with in gastric cancer. A carcinomatous metastasis in the 
thorax is accompanied by the symptoms of pleurisy (dulness, 
pains, friction sound). Although these metastases, as a rule, 
appear quite late, still if present they may help to clear the 
diagnosis. 

'Boa-: "Spec. Diagnostik und Therapie der Magcnkrankhoiten," 2te 
Aufl.. p. 186. 



296 DISEASES OF THE STOMACH. 

11. Gondii ion of the Blood. — Laache 1 first described a decrease 
of the number of red blood cells in this affection, while Haeber- 
lhr found that the haemoglobin was greatly diminished. 
According to this writer, the quantity of the latter is only fifty 
per cent, of the normal. Eisenlohr 3 and Schneider 4 found an 
increase of the leucocytes. While all these conditions are of 
some importance, as suggestive of cancer, they are by no 
means specific and are met with in other affections. 

Recently Schneyer 5 has stated that the usual increase in the 
number of leucocytes, which is found normally during the period 
of gastric digestion, is absent in all cases of gastric cancer; that 
is, the number of leucocytes in the fasting condition and at the 
height of gastric digestion remains the same. This symptom 
promises to be of great value, and it should certainly be further 
investigated. 

12. Condition of the Urine. — Klemperer 6 and Mliller 7 dis- 
covered that the urine in cases of gastric cancer contains more 
nitrogen than the amount introduced with the nourishment. 
It has been found, however, that this symptom is not con- 
stantly present. Besides, the elucidation of this fact necessi- 
tates quite complicated and laborious investigations, which 
can be made only in clinics, but not in private practice. The 
amount of chlorides is frequently found diminished, while the 
indigo-forming substances are often increased. Peptonuria is 
occasionally observed; it always indicates that there is absorp- 
tion from an ulcerated area (neoplasm) within the digestive 
tract, and is therefore of importance. 

According to Salkowski the colloidal nitrogen in the urine is 

1 S. Laache: "Die Anamie," Christiania, 1883. 

2 Haeberlin: Munchener med. Wochenschrift, 1888, No. 22. 

3 Eisenlohr: Deutsch. Arch. f. klin. Med., Bd. 30, p. 495. 
4 G. Schneider: Inaugural Dissertation, Berlin, 1888. 

5 Schneyer: Zeitschr. f. klin. Med., 1895. 

6 G. Klemperer: Berl. klin. Wochenschr., 1889, No. 40. 
7 Fr. Muller: Zeitschr. f. klin. Med., Bd. 16, p. 496. 



CAXCER OF THE STOMACH. 297 

considerably increased in cancerous affections. Rosenbloom 
and I have been able to confirm this statement. The future 
will show in how far this new fact can be utilized for the 
early diagnosis of cancer. 

B. Symptoms Produced by the Position of the Growth. — These 
may be divided into three groups, according to the location of 
the growth. 

(a) Cardia. Subjective Symptoms. — Dysphagia is one of the 
principal symptoms of cancer of the cardia. The patient first 
notices that he cannot eat as fast as he would like. Frequently 
he has to stop in the middle of a meal, experiencing a sensation 
as if the food would not go down into the stomach. This 
occurs only if solid food is taken. The patient, as a rule, 
learns to help himself by chinking several mouthfuls of water 
when such an impediment occurs. Very soon these difficulties 
increase in severity and in number, and the patient can hardly 
partake of solid substances without drinking liquids with them. 
Still later, the patient finds it impossible to partake of solid 
food, as he cannot force it down into the stomach even by 
means of water. Whenever he tries to do so, the food remains 
within the oesophagus and causes a feeling of extreme discomfort 
and oppression. The patient is then usually obliged to eject it 
after much straining and retching. Liquid food is at this time 
the only diet on which the patient subsists. Still later, when 
the stenosis is of a very high degree, the patient is unable to 
partake even of a sufficient quantity of liquids, as he can force 
through the stenosed cardia only very small amounts or none 
at all. Besides these difficulties in eating and drinking, the 
patient often complains of either pains or a burning sensation 
at the scrobiculus and somewhat above it. " Vomiting," or, 
more correctly, ejection, of some mucus with or without food 
particles from the oesophagus often occurs, especially at night, 
in the recumbent position of the patient. 

Objective Symptoms. — 1. Svjallowing sound. The swallowing 



298 DISEASES OF THE STOMACH. 

sound, if not absent, is frequently retarded, and heard about 
twenty seconds after swallowing of water, while normally it 
should be heard after seven. This sign, however, is not pathog- 
nomonic; for, on the one hand, I have seen cancer of the cardia 
with the appearance of the swallowng sound at the normal 
time of seven seconds; and, on the other hand, I have observed 
cases in which there was no organic trouble and still the 
swallowing sound was not heard for a long time. 

2. Examinations with the tube. It is best to examine the 
patient with silkworm tubes or olive-shaped bougies of dif- 
ferent sizes. For the sake of convenience the latter may be 
made in a divisible form, thus enabling them to be carried 



® 



G. TIEMANN & Co., N. Y. 



Fig. 82. — Einhorn's Divisible (Esophageal Bougie. 

in the physician's pocket (Fig. 82). The examination should 
be directed with the following objects in view: 

Permeability. — It is of the utmost importance to introduce 
the tube through the oesophagus into the stomach, and to pay 
attention to the fact whether there be no resistance at any place 
of the passage. If a resistance is felt, mark at what distance 
from the mouth it is situated, and also whether it can be over- 
come without the application of much force. Much force should 
never be exerted; if a tube of a certain thickness has met with 
resistance within the cesophagus, then try a tube of thinner 
calibre. In this way the degree of stenosis can be estimated. 

Particles of Tumor. — When withdrawing the tube from the 
cesophagus, it is always necessary to close the opening with 



CAXCER OF THE STOMACH. 299 

the thumb, and then empty the contents into a procelain dish. 
Sometimes small particles of the neoplasm are then found, 
which, when examined under the microscope, will frequently 
reveal the nature of the trouble, and assist us in making a 
positive diagnosis of cancer. 

Blood. — The tube sometimes contains either fresh clear 
blood, not smelling badly, or blackish-looking and decomposed 
blood mixed with mucus, with a very disagreeable, sometimes 
fetid odor. The latter condition is very frequently found in 
malignant strictures of the cardia, and is sometimes pathog- 
nomonic of cancer. Fresh, clear blood, appearing constantly 
at the examination of the tube, is suggestive of malignant 
trouble at the cardia, even when no stricture has yet been 
found. This symptom, however, is not a positive one, as there 
are other conditions that may produce it. The following case 
well illustrates the importance of the detection of blood at the 
lower end of the oesophagus: 

Patient-, about 45 years old, had complained of a burning 
sensation and pains in the epigastric region for over a year. He 
had no difficulty whatsoever in the partaking of food. He was 
not emaciated and presented a healthy, good color. On exami- 
nation, the gastric region was found to be somewhat tender, 
but not painful to pressure. The outlines of the stomach were 
not enlarged. The swallowing sound was heard seven seconds 
after the deglutition of water. The examination with the tube 
one hour after test breakfast revealed no abnormal conditions 
whatever. The tube passed into the stomach without the 
slightest resistance. The chemical analysis of the gastric con- 
tents showed the presence of free hydrochloric acid, the absence 
of lactic acid, and a degree of acidity of GO. On washing out the 
stomach of the patient in the fasting condition, it was found that 
it rontained no food from the previous day, and the water 
returned pretty clear. "When, however, the water stopped 
running and the tube was partly withdrawn, so that its end was 
in the noi^hborhood of the cardia, a small quantity of clear blood, 
mixed with some water, usually ran out. When the upper 



300 DISEASES OF THE STOMACH. 

opening of the tube was closed and the instrument entirely 
withdrawn, it was found to contain pretty clear blood. Nu- 
merous examinations during a period of about two months showed 
the presence of the same condition, especially with regard to the 
appearance of blood at the end of the washing procedure or 
when withdrawing the tube. The characteristic rest treatment 
for ulcer did not benefit the patient in the least. The probable 
diagnosis of cancer of the cardia was made, and the patient died 
one year afterward in a well-known sanitarium in Germany, in 
which the diagnosis of cancer had been confirmed. 

3. Retention of Food within the (Esophagus. — In most instances 
of cardiac stenosis some of the food particles remain within the 
oesophagus above the stenosed spot. As a rule, they be- 
come decomposed and cause an irritation or inflammation of 
the oesophageal walls. The retention of food within the oesoph- 
agus is an important sign, and can be discovered one hour after 
the partaking of a small meal, in the following way: A tube of 
ordinary size (not too narrow) is introduced into the oesophagus 
until about 1 or 2 cm. above the stenosed spot, and the patient 
ordered to compress his thorax after a deep inspiration. As 
a rule, some contents now appear through the tube. The 
opening is then closed, the tube withdrawn and emptied, and the 
obtained contents examined as to appearance (macroscopical 
aspect), reaction, whether acid or not, whether containing 
lactic acid, hydrochloric acid, or the ferments. A tube of 
thinner calibre which can pass the stricture is then taken, and 
introduced into the stomach. 

By the ordinary expression method the real gastric contents 
are now obtained. Their macroscopical appearance, as well 
as their chemical condition — which again refers to acidity, 
presence of hydrochloric acid, and ferments — is compared 
with the portion first obtained by means of the thicker tube. 
In cases of actual retention of food within the oesophagus, the 
first portion shows the following characteristics: Reaction, 
either neutral, alkaline, or slightly acid; hydrochloric acid and 



CANCER OF THE STOMACH. 301 

ferments absent; organic acids occasionally present. The 
particles of food appear unchanged in any way and are in just 
the same condition as when swallowed. The second portion, 
obtained from the stomach, presents the appearance of chyme, 
shows a decided acid reaction, the presence of hydrochloric 
acid either in its free state or combined, frequently the 
presence of ferments, especially rennet, and gives the biuret 
reaction. 

Retention of food within the cesophagus is not pathognomonic 
of cancer of the cardia, as it is also found in dilatation of the 
oesophagus, caused either by a benignant stricture of the cardia 
or by a disturbance of the peristaltic action of the cesophagus. 
The latter two conditions, however, are quite rare, so that the 
symptom of retention is of much importance in the diagnosis of 
cancer of the cardia. 

4. The examination with the cesophagoscope often shows a 
neoplasm. 

(b) Pylorus. Subjective Signs. — Besides the pains, there 
exist a decided feeling of fulness and quite frequent attacks of 
vomiting. 

Objective Signs. — 1. Tumor. A tumor can very frequently 
be discovered, situated somewhat to the right of the linea alba 
in the area extending from the navel to the ribs. The methods 
of diagnosing these pyloric neoplasms have already been 
described above. 2. Vomited matter. This consists of large 
quantities of chyme (one to two quarts or more), and, as a rule, 
contains food which had been taken a day or two before the 
act of vomiting. 3. Ischochymia. This condition (retention 
of chyme) is very pronounced. On examining the stomach in 
the fasting condition of the patient by means of the tube a 
considerable quantity of chyme, containing more or less decom- 
posed food from previous days, is found. Very frequently the 
particles of food are quite coarse and obstruct the openings of 
the tube. In such instances it is often very difficult to empty 



302 DISEASES OF THE STOMACH. 

the stomach entirely, oven by means of washing. This object 
can hardly be achieved in one sitting. 

(c) Stomach Proper. Subjective Symptoms. — 1. Pains. A 
constant gnawing pain in the scrobiculus cordis radiating to 
the back is frequently found present. 2. Anorexia is very 
marked. 

Objective Symptoms. — 1. Tumor. The presence of a tumor 
situated to the left of the linea alba (see page 290). 2. Vomit- 
ing of small quantities of food, frequently presenting a blackish 
color. 3. Ischochymia of a slight degree. The examination 
by means of the tube of the stomach in the fasting condition 
reveals the presence of a small quantity of chyme, the particles 
of food therein being quite minute. 

Diagnosis. — The diagnosis of cancer of the cardia is made 
from a study of the above-described symptoms and the results 
of the examination with the tube. Cancer of the pylorus and 
stomach proper is diagnosed in the same manner. Although 
the hope of finding certain pathognomonic characteristics in the 
chemical condition of the gastric contents with cancer of the 
stomach has not been realized, still the chemical analysis 
reveals several points which certainly aid in establishing the 
diagnosis of the affection in question. Van den Velden, 1 in 
1879, first stated that hydrochloric acid is absent in gastric 
cancer. He made use of certain aniline dyes (Congo and 
methyl violet) for the detection of this acid. Cahn and von 
Mering 2 made use of an exact analytical method, and found 
that in some cases of gastric cancer the stomach contents 
revealed considerable quantities of hydrochloric acid. Ewald 
justly mentions in his book that the question as to the presence 
or absence of hydrochloric acid in gastric cancer had been 
experimentally broached as far back as 1842 by the English 



1 Van den Velden: Arch. f. klin. Med., Bd. 22, p. 369. 

2 Cahn und von Mering: Berl. klin. Wochenschr., 1885. 



CANCER OF THE STOMACH. 303 

physician Golding Bird. 1 In a man forty-two years old, with 
pyloric cancer and dilatation, this writer determined the 
relation of hydrochloric and organic acids in a series of examina- 
tions of the vomit. The results of these examinations led Bird 
to conclude that "during the most irritative stages of the 
disease free hydrochloric acid is present in the vomit in con- 
siderable quantities, but it gradually diminishes in propor- 
tion to the patient's loss of strength, and that the organic 
acids increase proportionally as the free hydrochloric acid 
diminishes.'' 

In forty cases of gastric cancer Boas 2 found an absence of 
hydrochloric acid in thirty-five, while in the remaining five 
free hydrochloric acid was discovered. Among the cases of 
gastric cancer that I have seen during the last few years, I 
know of six in winch free hydrochloric acid was present, either 
in normal or in greater quantities. These cases of gastric 
cancer in winch hydrochloric acid is found to exist certainly 
lessen the value of Van den Velden's symptom for the recog- 
nition of the disease; but this symptom loses still more in 
importance if we consider that absence of free hydrochloric 
acid is associated with many other conditions besides cancer. 
Severe forms of gastric catarrh, and especially achylia gastrica ? 
will undoubtedly furnish a greater contingent of cases with 
absence of hydrochloric acid than cancer of the stomach itself. 

Lactic Acid. — Although it was known that the organic acids 
are increased in cancer of the stomach, and that lactic acid 
frequently occurs, Boas 3 must be credited with laying stress 
upon the presence of lactic acid in this affection; he even 
attributed a pathognomonic value to this symptom. According 
to this investigator, lactic acid, if not introduced in a preformed 



'Golding Bird: "Contributions to the Chemical Pathology of some 
Forms of Morbid Indigestion." London Med. Gazette, 1842, p. 391. 

2 Boas : I. c. 

3 J. Boas: Deutsche med. Wochenschr., 1892, Xo. 17. 



304 DISEASES OF THE STOMACH. 

state with the food, but developing in the stomach, occurs 
exclusively in cancer of this organ. After a thorough washing 
of the stomach, Boas gives the patient a test meal, consisting 
of a plate of barley soup. One hour afterward the gastric 
contents are obtained and examined, either by the Uffelmann 
test or by Boas' method, as to the presence of lactic acid. 
This test meal does not contain any lactic acid, and if the latter 
is found to be present then it must have been produced in the 
stomach. Boas does not deny that there are cancers of the 
stomach which do not show this symptom. As a rule, these 
are cases in which hydrochloric acid is found to be present. 
The occurrence of lactic acid, however, is, according to Boas, 
a specific sign. Many writers have of late investigated the 
question of the appearance of this acid. Most of them agree 
that lactic acid exists in large quantities in the majority of 
cases of gastric cancer, but that it is by no means a specific 
sign. Klemperer, 1 Thayer, 2 Rosenheim, 3 and myself/ have 
published cases of non-malignant gastric troubles in which 
lactic acid was found in the gastric contents. 

The absence of free hydrochloric acid and the presence of 
lactic acid, although they are, as we have seen, not pathog- 
nomonic, are, however, of importance and frequently help to 
establish the correct diagnosis. 

Neubauer and Fischer 5 have recommended the glycyl- 
tryptophan test for the diagnosis of gastric cancer. Glycyl- 
tryptophan is added to the gastric filtrate and kept at blood 
temperature for 6-24 hours. If tryptophan has been split off — 
as can be demonstrated by bromine vapor or Aq. bromi turning 
the fluid reddish — this speaks for cancer. For gastric juice, 

1 Klemperer: Deutsche med. Wochenschr., 1895. 

2 Thayer: Johns Hopkins Hosp. Bullet., 1893, No. 31. 

3 Rosenheim: Berl. klin. Wochenschr., 1894, No. 39. 

'Max Einhorn: "Stenosis of the Pylorus." Medical Record, January 
19th, 1895. 

5 Neubauer und Fischer: Deutsch. Arch. f. klin. Medicin, 1909, Bd. 57. 



CAXCER OF THE STOMACH. 



305 



as a rule, does not decompose glycyl-tryptophan. Ley 1 and 
others have, however, discarded this new test as unreliable. 

X-ray examinations are likewise of help in recognizing the 
presence or absence of tumors of the stomach. The two fol- 
lowing radiograms may serve as illustrations (Figs. 83 and 84). 

The diagnosis of cancer can be positively made under the 
following conditions: 




Fig. 83. 

1. If particles of tumor are found (in the wash water or in 
the tube), which under the microscope reveal the characteristic 
picture of a malignant growth. 

2. The presence of a more or less large tumor with an uneven 

1 H. Ley: "Zur Diagnrw des Magencarcinoms mittels der Fischer-Neu- 
bauerochen MfThode der Spaltung des Glycyl-tryptophans." Berl. klin. 
Wochenschr., 1011, p. 119. 
20 



306 



i >isi ;asi;s or Tin-; stomach. 



surface, belonging to the stomach and associated with dyspeptic 
symptoms. 

3. The presence of a tumor associated with frequent 
haematemesis. 

4. Constant pains, frequent vomiting, ischochymia, emacia- 
tion — all these symptoms being quite permanent and not 
extending over too long a period of time (six months to one 
year). 




Fig. 84. 



5. Tumor and ischochymia. 

6. Emaciation, ischochymia, presence of lactic acid. 

7. Constant anorexia and pains, not yielding to treatment, 
accompanied by frequent small hemorrhages (of corTee-ground 
color) or the presence of occult blood. 

Differential Diagnosis. — In cases in which a tumor exists it is 
necessary to determine whether it originates from the stomach 
or some other organ; and if it has its seat in the stomach, 
whether it is of benign or malignant character. The first 



CANCER OF THE STOMACH. 307 

question, as to which organ a tumor belongs, has been discussed 
above. As regards the second question, we shall have to 
differentiate between a tumor situated within the stomach 
proper and one at the pylorus. Benign tumors, like fibroma, 
myoma, and lipoma 1 situated within the stomach, or foreign 
bodies, like a gastrolith or a mass of hair, which ma}^ simulate 
a neoplasm are of extremely rare occurrence and need hardly 
be taken into consideration when making the diagnosis. In 
tumors situated at the pylorus we meet much more frequently 
conditions of a benign type, such as cicatricial thickening or 
simple hypertrophy. The size of the tumor, the condition of 
its surface, whether smooth or nodular, will frequently help 
to decide this question. The tumor in benign processes is 
usually not very large (about walnut size), smooth, and does 
not grow; while malignant growths are larger, frequently 
present an uneven surface, and increase in size. These points 
are, however, not enough to form a decisive opinion, and they 
must be supplemented by such data as can be obtained. Thus, 
long duration of the sickness — two or three years and more — 
speaks in favor of a benign process, while a short duration — 
six months and so on — rather favors the view of a malignant 
process. 

In all instances in which a tumor is absent the differential 
diagnosis of cancer will have to exclude ulcer, benign stenosis 
of the pylorus (not palpable), chronic gastric catarrh, achylia 
gastrica, and very severe forms of gastric neurasthenia. 

1. Ulcer. — In ulcer there is, as a rule, a clear tongue, a 
circumscribed spot painful to pressure, some connection of the 
pains with the period of gastric digestion, intervals perfectly 
free from pain, very large hemorrhages, not recurring very 
frequently, and, as a rule, no real anorexia. In cancer, on the 

1 Syphilitic gummatous tumors of the stomach also belong to this class. 
I have observed a case of this kind very recently. The presence of other 
luetic manifestations will remind us of this possibility. 



308 DISEASES OF THE STOMACH. 

other hand, the tongue is almost always thickly furred, the pain- 
ful area generally extends over the greater part of the gastric 
region, the pains not having much relation with the digestive 
period, the hemorrhages are rather small and very often 
recurring, and real anorexia or aversion for food exists. 

2. The benign stenosis of the pylorus gives a long history of 
sickness interrupted by intervals of almost perfect euphoria, 
extending over different periods of time (two or three months 
to one year) ; the gastric contents generally show the presence 
of free hydrochloric acid and an increased degree of acidity. 
Malignant stenosis of the pylorus gives a short clinical history, 
no intermissions, and the gastric contents most often do not 
contain free hydrochloric acid and reveal the presence of lactic 
acid in considerable quantities. The degree of acidity is vari- 
able, sometimes being greatly increased through organic 
acids. 

3. Chronic Gastric Catarrh. — A severe form of chronic gastric 
catarrh may at the beginning give rise to considerable difficulty 
in establishing the diagnosis between the two conditions. 
Sometimes this will be at first impossible. By keeping the 
patient under observation for a certain length of time the 
diagnosis will often clear up, the chronic catarrh will improve 
under rational treatment, while cancer of the stomach will 
either show no amelioration whatever or only a very slight 
one, the main symptoms of the disease continuing in the same 
way as before the institution of the treatment. 

4. Achylia Gastrica. — In achylia gastrica the tongue is some- 
times clear, the gastric contents showing no juice whatever, no 
mucus, very little fluid of neutral or very slightly acid reaction 
(acidity, 2 to 6), no ferments, no lactic acid. The particles of 
food are very coarse. The stomach is empty in the fasting 
condition of the patient; there are no hemorrhages. In gastric 
cancer the tongue is always furred, the gastric contents, as a 
rule, include considerable quantities of mucus, and the degree 



CANCER OF THE STOMACH. 309 

of acidity is much higher, even if there is absence of free hydro- 
chloric acid. The fragments of food are not so coarse as in the 
former condition, lactic acid is frequently found, and numerous 
micro-organisms are almost always, and occult blood often 
present in the contents. 

5. Severe Form of Gastric Neurasthenia. — A mistake between 
gastric cancer and severe forms of neurasthenia will not occur 
frequently. The neurotic condition which can be found in the 
patient, implicating several other organs besides the stomach, 
will help to establish the true diagnosis. 

Duration and Prognosis. — The malignant process usually 
terminates fatally about one year from the commencement 
of the symptoms. Cases, however, are met with in which 
the disease runs a more protracted course, eighteen months 
to two years. On the other hand, very acute, so-called fou- 
droyant cases are observed which end in death in from four 
to six weeks. The duration of the disease depends, firstly, 
upon the situation of the neoplasm, which causes more disturb- 
ances and rapid death when occupying and occluding the 
cardiac or pyloric orifice; secondly, upon the character of 
the growths (some of which, as, for instance, the medullary 
form, develop rapidly); and thirdly, upon the complications 
which arise either from ulceration and hemorrhage or from 
cancerous metastasis. 

The prognosis of cancer of the stomach is always hopeless. 
Oser justly said, the only hope for the patient can be that the 
physician has made a mistake in the diagnosis. No specific 
remedy has as yet been discovered for this ailment, and even 
surgery has not been able thus far to combat this malady 
successfully. 

Treatment. — The treatment comprises: A. Surgical inter- 
ference; B. Medical treatment. 

A. Surgical Interference.— Owing to the futility of medicinal 
treatment, surgical intervention has been invoked, and several 



310 DISEASES OF THE STOMACH 

bold operations have been devised, which may be resorted to 
in appropriate cases. These may be divided into radical and 
palliative procedures. 

a. The radical operations include: (1) Resection of the 
pylorus; (2) excision of the tumor. 

Billroth 1 was the first to prove the possibility of excision of 
the carcinomatous pylorus, in 1878. Since that time, distin- 
guished surgeons all over the world have been working in this 
special field of abdominal surgery, and have greatly contributed 
to the further development of this heroic method of treatment. 
The aim in total resection of the tumor is to radically cure the 
patient, i.e., to remove all the cancerous parts of the organ. 
It will be seen at a glance that the indications for this operation 
exist as soon as a neoplasm accessible to the knife and operable 
can be diagnosed. The earlier the diagnosis is made the better 
are the chances for radical interference. Thus far only very 
few cases are known in literature in which the excision of the 
tumor or the resection of the pylorus was followed by a real 
cure. The reason that these operative procedures have not 
been so successful as was expected, is that they are resorted 
to, as a rule, too late. Gastric cancer can rarely be diagnosed 
before it has contracted adhesions w T ith other organs, or before 
metastatic deposits have formed elsewhere. Contraindications 
for these operations are: (1) If cancerous metastasis can be 
discovered in other organs (liver, glands, etc.); (2) adhesions, 
i.e., if the tumor is not perfectly movable and found to be 
adherent to other organs; (3) the large size of the tumor; (4) 
the presence of high degrees of anaemia or cachexia; (5) very 
old age. 

b. Palliative Operations. — The palliative operations have two 
purposes in view: 

1. To permit of a better introduction of food into the 
digestive tract. 

1 Billroth: Wiener klin. Wochenschr., 1891, No. 34. 



CAXCER OF THE STOMACH. 311 

2. To remove as much as possible the irritating effect of 
food upon the affected area. 

The operations serving this object are: 

1. Gastrostomy, in malignant affections of the cardiac orifice 
or of the oesophagus. 

2. Gastroenterostomy, for malignant affections of the pylorus 
or its immediate neighborhood. 

Gastrostomy consists in establishing an opening between the 
stomach and the abdominal wall, in order to introduce food by 
this new passage. The technique of this operation has lately 
been considerably improved, WitzelV and -Sabanjeff-Frank's 
methods accomplishing the best results. The indications for 
this operation exist as soon as dysphagia is well developed and 
the patient unable to introduce large enough quantities of 
liquid and semi-liquid food through his oesophagus in order to 
maintain his bodily weight. To wait until a time when even 
small quantities of liquid cannot pass through the cardia into 
the stomach without discomfort and pain does not appear to be 
advisable, for at this period the operation, as a rule, is more 
dangerous and affords less relief to the patient. Contrain- 
dications for this operation are the weakened condition of the 
system, caused either by advanced cachexia, very old age, or 
other conditions. 

Gastroenterostomy consists in the establishment of a new 
communication between the stomach and the small intestine, 
in this way allowing the chyme to pass directly into the small 
intestine without previously passing through the pylorus. The 
indications for this operation exist as soon as the presence of 
malignant trouble within the organ has been diagnosed, com- 
plicated with symptoms of ischochymia, especially if a radical 
operation does not appear to be feasible. The sooner it is done 
the better. By means of it life can be considerably prolonged 
and made. much more comfortable than is possible by any other 

1 Witzel: Centralbl. f. Chirurg., 1891, No. 31. 



3 1 2 DISEASES OF THE STOMACH. 

treatment. The contraindications are the same as those given 
above under gastrostomy. 

Exploratory laparotomy, which is often performed in this 
disease, seems to be permissible only in those cases in which 
the diagnosis, although not positive, admits of the possibility 
of undertaking some kind of an operation which will afford 
either a cure or at least some relief to the patient. To make 
an exploratory laparotomy merely for the sake of diagnosis 
does not seem to me justifiable, 

B. Medical Treatment. — The medical treatment has the fol- 
lowing points in view: To strengthen the organism by a proper 
mode of nourishment, thereby prolonging life as much as possible, 
and to alleviate the morbid phenomena. The first point can be 
achieved by a proper diet. The more food the patient can be 
made to take and to assimilate the better. This should be the 
most important principle in guiding us. Ample variety in the 
bill of fare and the individual inclination of the patient will have 
to be considered. Trousseau said that the patient should be 
allowed to eat what he himself thinks he can best tolerate. 
The following may be given as general rules: The diet should 
consist of milk, kumyss, zoolak; farinaceous food; soups 
containing leguminous foods in a finely divided state (ground) ; 
eggs, either raw or soft-boiled, or well beaten up in soup or 
milk; small quantities of meat, either raw and well scraped, 
or broiled; the white meat of a chicken; squab, calf's brain, 
sweetbreads, oysters, fish, white French bread; crackers, with 
the addition of a small quantity of sweet butter; tea and coffee, 
wine, ale. In the later stages of the disease many articles of the 
just-described diet will not appear suitable, and the mainte- 
nance of nutrition becomes gradually more difficult. Here the 
artificial foods, the various peptone preparations (Wyeth's beef 
juice, Kemmerich's or Rudisch's peptone, Mosquera's beef 
jelly, somatose, sanatogen, Armour's beef peptone), are in place. 

Radium. — I have tried the radium treatment in cancer of the 



CAXCER OF THE STOMACH. 



313 



stomach as well as cancer of the oesophagus. I 1 have devised 
for this purpose radium receptacles for the stomach and 
oesophagus. 

The radium receptacle for the stomach consists of a hard- 
rubber capsule that can be screwed apart, the upper part of 
which is provided with an opening for the attachment of a silk 
thread (Fig. 85). The radium flask is inserted into this capsule, 
the latter is screwed together, the silk thread attached and 
knotted. The length of the latter must be about 75 cm. 
There should be knots at 40, 50, and 63 cm. The first knot 
(at 40 cm.) indicates the distance of the cardia from the lips, 





Geo.Tiemannx.Co 



Fig. 85. — Radium Receptacle for the Stomach. 

the second (50 cm.) how far the capsule should be distant from 
the cardia, and the third (63 cm.) the distance from the mouth 
to the lobe of the ear. 

The method for introducing the radium capsule is the same 
as that for the introduction of the stomach bucket. The 
radium is kept within the stomach for one hour, then removed. 

The radium receptacle for the oesophagus consists of a rubber 
tube (about 17 F. diameter) which is provided with a mandrin 
and a capsule, the lower part of which is made of hard rubber 

Einhorn: "Radium Receptacles for iho Stomach, (Esophagus, 
ctum." Medical Record, March 5th, 1904. 



314 



DISEASES OF THE STOMACH. 



and the upper part of metal. The two halves are screwed 
together. The upper part of the capsule is provided with a 
screw thread by means of which it is attached to the tube 
portion (Fig. 85). 

The capsules are made in three different sizes to fit strictures 
of various widths. 

Mode of Application. 

The radium vial is placed in the capsule of the instrument and 
the latter screwed tightly together. The apparatus with the 




Fig. 86. — The (Esophageal Receptacle with Tubing and Mandrin. 

mandrin, having been first immersed in warm water, is intro- 
duced into the oesophagus, with the patient in the sitting posi- 
tion (best in the fasting condition), and is pushed forward to the 
stricture. In introducing it, it is best to depress the tongue 
with the left index finger and to hold the instrument like a pen 
in the right hand, compressing it somewhat so that the mandrin 
remains in place. When the stricture has been reached, as 
evidenced by the resistance, the mandrin is removed and the 
end of the rubber tubing fastened by means of a thread to 
the ear of the patient. The instrument is allowed to remain 
in the oesophagus from one-half to an hour, according to the 
needs of the case, and is then removed. 

When employing the larger capsule it is necessary when 



CANCER OF THE STOMACH. 315 

withdrawing the instrument to make the patient swallow- 
when the cricoid cartilage is reached in order to avoid the 
resistance encountered at this spot. 

After having removed the instrument, wash it, unscrew the 
capsule, open it. and remove the radium vial. The instrument 
may be easily disinfected. 

The same instrument may also be used in gastric carcinoma. 
It must then naturally be introduced into the stomach. 

Within the last year I have used radium applicators made 
of whalebone (see Fig. 87), one for the pylorus (A), and another 
for the oesophagus and stomach (B). The pyloric instrument 
has to be inserted over the thread of the duodenal bucket (or 
olive), taken the night previous. The other instrument for the 
oesophagus and stomach is introduced without any special 
preparation, excepting that it is best done in the fasting 
condition of patient. 

Sometimes it is desirable to apply the radium for a longer 
time (6 hours or more). It is also necessary to be sure that the 
radium is just there where we need it. For this purpose the 
capsule with the radium attached to a long thread may be 
inserted at the desired place (within the oesophagus or stomach) 
by the radium introducer (see Fig. 88). 

With regard to the action of the radium in cancer of the 
stomach I have, thus far, treated too few cases to form a definite 
conclusion. It seems to be of palliative benefit. 

In cancer of the cesophagus I 1 have had more experience 
with this mode of treatment. I have applied the radium . 25 
gm. (Curie, 20,000 strength) daily in about 20 cases and . 07 
gm. of the pure radium bromide half an hour daily in 4 cases, 
and have achieved an improvement in most of them. 

In some of the cases the stricture did not become passable; 
the bougie, however, could be introduced deeper. In some the 

1 Max Einhorn: "The Radium Treatment of Cancer of the (Esophagus." 
Journ. American Med. Assoc., 1905. 



316 



DISKASKS OF THE STOMACH. 



stricture became passable for rather thick bougies (43-52 F.). 
The improvement could usually be observed after a week's 
treatment, at times even earlier. 





All these patients felt better than they did before treatment; 
most of them could swallow better; some, in whom the stricture 
had become entirely permeable, were able to take semisolid and 



CAXCER OF THE STOMACH. 317 

even solid food. The pain was less in the larger majority of the 
cases. 

The results obtained are very satisfactory, since we have to 
deal with an affection which has not been amenable to treat- 
ment until now. In the methodical application of radium we 
have the means to influence favorably the course and seat of the 
disease and to retard its progress, even if at present we cannot 
entirely remove it. This mode of treatment is certainly 
destined to play an important role in the therapeutics of cancer 
of the oesophagus and deserves to be tried on a large scale and in 
a thorough manner. 

Medicinal Treatment. — As yet no specific remedy against 
cancer has been found. The treatment must, therefore, be a 
palliative one, and chiefly directed toward combating the more 
pronounced morbid manifestations and alleviating pain. In 
cardiac strictures Boas 1 recommends the use of potassium 
iodide. This author reports a case of oesophageal cancer in 
which he employed sodium iodide (2 to 3 gm. pro die) for over 
six month. During this whole period the patient remained free 
from symptoms, and even gained nine pounds in weight. I 
have also administered this drug in several cases of cardiac 
stenosis, and frequently obtained transient good results. 
Recently I have made use of the following: 

T£ Thiosinamin, 0.2 

Spirit, vin. rectif., 

Syr. cort. aurant aa 30.0 

D. S. One teaspoonful t. i. d. 

Arsenic has also been given in this affection (Fowler's solu- 
tion, three drops three times daily), sometimes with good 
results. One of the principal remedies which are employed in 
gastric cancer is r-ondurango. This drug was recommended in 
1874 by Friedreich 2 as a specific against cancer. While, how- 

1 Boas: I. c. 

edreich: Berl. klin. Wochenschr.. 1874. 



318 DISEASES OF THE STOMACH. 

ever, further researches did not substantiate this favorable 
report, but rather proved that condurango has in no way a 
specific action on cancer, many writers agree that it is an 
excellent stomachic and as such helps greatly to alleviate some 
of the gastric symptoms accompanying malignant affections of 
the stomach. Ewald, Rosenheim, Boas, strongly advocate the 
use of this drug. I also administer it in the greater number of 
cases. Ewald usually employs it in combination with hydro- 
chloric acid. Condurango may be given in the form of a decoc- 
tion, 25 to 200 gm. water, one tablespoonful every four hours; 
or in the form of fluidextract, of which twenty drops or even 
more can be given three to four times daily. Another drug 
from which I have sometimes seen beneficial effects in this 
malady is methylene blue. I 1 was the first to recommend its 
internal use in cases of cancer. I have employed it in eight 
cases of cancerous affection of either the oesophagus or the 
stomach. In three of these cases I was able to note a great 
improvement of most of the morbid phenomena. In one case, 
in which a considerable tumor occupied the gastric region, this 
appeared to have become somewhat smaller after the drug had 
been used for about three weeks. This patient took methylene 
blue for a period covering eight to nine months uninterruptedly, 
being all the time quite free from pain and not losing in weight, 
the tumor meanwhile not getting any larger. After this period, 
however, the tumor began to grow again and the patient rapidly 
succumbed. Methylene blue is best given in gelatin capsules, 
. 2 gm. once or twice daily. While I do not believe that this 
drug is able to cure a cancerous disease permanently, I am of 
the opinion that it seems to exert a beneficial action in some 
cases of cancer. 

In all cases in which either decomposition of food or ulcera- 
tion is taking place, one of the best remedies to alleviate these 

1 Max Einhorn: " Ueber die Anwendung des Methylenblau." Deutsche 
med. Wochenschr., 1891, No. 18. 



CAXCER OF THE STOMACH. 319 

conditions, and also subdue the discomforts produced by them, 
is chloral hydrate. Ewald was the first to advise its use, and I 
also advocate it highly. It may be given in the form of a 
three-per-cent. solution, one tablespoonful every two or three 
hours. The remainder of the remedies employed is simply 
symptomatic; thus, in case of pain, opium, morphine, or codeine 
must be administered. The combination of an opiate with 
belladonna is very suitable. If there should be a profuse 
hemorrhage, this will have to be treated. similarly to that pro- 
duced by ulcer. Obstinate vomiting must be controlled either 
by opiates or, in instances in which vomiting is due to stag- 
nation of food in the stomach, by occasional lavage. Con- 
stipation, which is so frequently present, must be relieved, 
either by mild aperients (rhubarb, compound licorice powder, 
cascara sagrada), or by enemata, or glycerin suppositories. 
Occasionally the following pills may be prescribed: 

1$ Extr. aloes, 

Extr. rhei comp aa 2.0 

M. f. pil. Xo. xx. D. S. One to two pills in the evening. 



CHAPTER IX. 

FUNCTIONAL DISEASES WITH VARIABLE 
LESIONS. 1 

Hypersecretion. 
Hyperchlorhydria. 

Synonyms. — Hyperacidity; hypersecretion. 

Definition. — The term hyperchlorhydria is applied to a con- 
dition in which the gastric secretion is more acid than 
normally and richer in ferments. Frequently the quantity of 
juice is also increased, but it is secreted only during the period 
of digestion ("digestive or alimentary hypersecretion"). 

General Remarks. — While the older writers were acquainted, 
to a certain extent, with digestive disorders attended with 
hyperacidity of the gastric juice, it is but quite recently that 
these conditions have been thoroughly studied and placed on 
an exact scientific basis. Formerly it was thought that in 
most disturbances of the stomach the gastric secretion was 
deficient. Nowadays, since the publications of Riegel, 2 Reich- 
mann, 3 Jaworski and Glusinski, 4 Ewald 5 and others, we know 
that in almost one-half of all the patients suffering from 
digestive disorders the gastric juice is rather increased. 

1 This heading comprises affections in which either the secretory or the 
motor function (prochoresis) of the stomach is at fault, forming the principal 
symptoms. Anatomical lesions here are not always present and if present 
are often of various kinds. 

2 Riegel: Zeitschr. f. klin. Med., Bd. 11 and 12. 

3 Reichmann: Berl. klin. Wochenschr., 1882, No. 40; 1884, No. 48; 
1887, No. 12. 

4 Jaworski: Zeitschr. f. klin. Med., Bd. 11, Heft 2 und 3. 
6 Ewald: I. c. 

320 



HYPERCHLORHYDRIA. 321 

According to my own experience, the gastric disorders 
accompanied with hyperehlorhydria form more than one-half 
of the number of patients troubled with digestive affections. 
With reference to this point the following table, which I pub- 
lished in the Medical Record of November, 1895, may be of 
interest : 

Table of Private Patients whose Gastric Contents have been 
Analyzed During 1889 to 1895. 

Xumber of patients with hypo- f in 89 : HC1 = 0, acidity = 2 to 40 

chlorhydria, 187, . . . .1 in 31 : HC1 = 0, acidity =40 to 80 

[ in67:HCl + , acidity = 15 to 40 

Xumber of patients with eu- 1 . ni uni . . ,., . n . _ A 

.,-».«* > m 91 : HC1+, acidity = 40to 60 

chlorhvdna, 91, I J 



Xumber of patients with hyper- \ 
chlorhydria, 286, ....'/ 

Total number of patients, 564. 



in 286 : HC1 + , acidity = 60 to 140 



Thus more than one-half of the cases showed a hyperacid state 
of the gastric juice. 

"Whether hyperacidity should be considered as a disease sui 
generis or not, is difficult to decide. Hyperacidity certainly 
describes only one symptom, showing that the secretory 
function is increased without pointing to any definite anatom- 
ical lesion; but this symptom may be of the greatest importance, 
and very often covers the whole ground upon which is based 
the subjective suffering of the patient and the rational treat- 
ment at our command. That is the reason why I think it best 
to discuss hyperehlorhydria in a special chapter. 

Does hyperehlorhydria always give rise to digestive disturb- 
ances and other symptoms? In order to answer this question 
it will be best to determine more exactly where hyperehlor- 
hydria begins — i.e., to what degree of acidity we may apply 
this term. According to the experience of Ewald and others, 
to which I can add my own, the degree of acidity of the gastric 
contents about an hour after EwalcTs test breakfast varies, as a 
rule, in healthy people between 40 and GO. A degree of acidity 

21 



322 DISEASES OF THE STOMACH. 

of 70 and above is therefore considered as hyperacidity. The 
above question will now be put in the following way: Must 
people with an acidity of their gastric contents of 70 and above 
always present morbid phenomena? To this I must answer 
in the negative. From a very large experience, I can assert 
that we occasionally meet with persons whose degree of acidity 
of the gastric contents is as high as 100 and even more, without 
producing any disturbances whatever. This condition need not 
even be a transient one, but may last for years and still cause 
no discomfort. This, however, is not the rule, and the greater 
number of persons with a hyperacid juice are not free from 
disturbances, but rather present a very characteristic train 
of symptoms. We speak of a pathological hyperchlorhydria 
whenever this condition is associated with subjective com- 
plaints. 

Etiology. — As has been just stated, hyperchlorhydria is of 
very frequent occurrence. It is met with chiefly in adults, 
although neither the young nor the old are exempt. In the 
majority of cases its origin may be traced either to a psy- 
chological cause, such as grief or worry, or to mental overwork. 
It is, as a rule, more frequent among the wealthier and more 
educated class of people, as lawyers, bankers, etc., although 
hyperchlorhydria may be met with also among the poor. But 
in addition to this so-called reflex action of the brain as an 
etiological factor of the disease, there may also be direct causes; 
thus, for instance, the habit of taking highly spiced dishes, 
much ice water, and strong alcoholic drinks, also the excessive 
use of tobacco are liable to produce this trouble. 

Symptomatology. — This disorder is usually characterized by 
a gradual development. At first the patient experiences an 
uneasy sensation about two or three hours after dinner. Later 
this changes into a feeling of distress in the epigastric region, 
occurring about two hours after each meal, instead of after 
dinner alone. The pain lasts for an hour or two, or even three,. 



HYPERCHLORHYDRIA. 323 

and then disappears. Very often pyrosis accompanies the 
pain and occasionally regurgitation or water brash takes place. 
The patients, as a rule, can ease their pain by taking some 
nourishment, especially one that is rich in albumin; thus the 
white of an egg, milk, or meat is capable of dispersing the pain. 
It also disappears after the ingestion of some alkali, as Vichy 
water or bicarbonate of soda. The appetite is ordinarily not 
diminished but frequently rather increased. Thirst is generally 
enhanced. The bowels in most cases are constipated. 

The composition of the food is frequently of significance with 
reference to the character of the pains, which are less intense in 
people partaking of large quantities of meat and eggs, while 
they are much more severe in persons living on a chiefly vege- 
table diet. 

Besides the attack of pain, patients affected with hyper- 
chlorhydria very often suffer from severe headache or attacks 
of dizziness, which may appear either independently or accom- 
panied by gastric pains. The patients, as a rule, do not lose 
in weight except in some rare instances, in which a faulty and 
insufficient diet has been maintained for quite a long time. 

Objective Symptoms. — On palpation the gastric region is fre- 
quently found tender on pressure, although not actually pain- 
ful, this tenderness not being limited to one circumscribed spot, 
but to a larger area covering the greater part of the gastric 
region. The contour and the size of the stomach are frequently 
found enlarged, although this condition is by no means charac- 
teristic of the affection in question. A splashing sound can be 
produced after the ingestion of water or after meals, but not 
in the fasting condition. 

On examination of the stomach with a tube in the fasting 
condition it is found to be empty, or only a few cubic centi- 
metres (five to ten) of the gastric juice can be obtained. One 
hour after Ewald's test breakfast, or two to four hours after 
Leube-Riegel's tesl dinner, the gastric contents include an 



324 DISEASES OF THE STOMACH. 

abundance of hydrochloric acid and of the ferments, the acidity 
being, as a rule, much higher than normally (twice or three 
times as high). A disc of egg albumen becomes digested in the 
jilt rate of these contents in a very short time (sometimes in 
half an hour). The gastric contents obtained three to four 
hours after the test dinner show macroscopically that the meat 
has been perfectly digested, while starchy substances are yet 
either unchanged or very little altered. The filtrate of the gas- 
tric contents, either after the test dinner or after the test break- 
fast, will reveal the presence of either starch or large quantities 
of erythrodextrin. The addition of a few drops of Lugol's 
solution to the filtrate will produce either a blue color or an 
intense dark red. 

The high degree of acidity is most commonly caused by free 
hydrochloric acid. The amount of fluid is frequently increased 
caused by a greater amount of gastric secretion, "digestive 
hypersecretion." The difference between the amount of free 
hydrochloric acid (as determined by Mintz's or Toepfer's 
method) and the total acidity is not great, the figure very 
frequently being from 10 to 20. 

The motor faculty of the stomach is usually not impaired; 
in a few instances it is rather increased. Thus two hours after 
the test breakfast, or six to seven hours after the test dinner, 
the stomach is found to be either empty or to contain but very 
little food. The salol test likewise shows salicyluric acid in the 
urine as early as an hour after the ingestion of the salol. 

The degree of acidity of the urine is frequently diminished 
during the digestive period. This, however, is not always the 
case, for occasionally the degree of acidity of the urine and of 
the gastric contents may be found increased at the same time. 

Course. — At the beginning hyperchlorhyclria is most fre- 
quently intermittent. The patient may suffer from this affec- 
tion for several days, weeks, or even months, becoming free 
from the ailment for periods of time which vary from several 



HYPERCHLORHYDRIA. 325 

weeks to months or even years. After this interval the trouble 
either recurs spontaneously without any apparent cause, or is 
evoked by a severe mental shock or worry. Later on the 
periods of remission may become shorter, the periods of hyper- 
chlorhydria longer, and at last this condition may become 
permanent. 

The following is a typical case of hyperchlorhydria: 

N. B. , 23 years old, complained for the last two and a 

half years of digestive disturbances which consist in pyrosis, 
dryness in the throat, drowsiness, and constipation. These 
symptoms were always present and became aggravated at 
certain periods of time. Patient has never lost much in weight. 
For the last three months patient suffered from pains in the 
gastric region. These appear quite regularly one and a half to 
two hours after meals, and last for one and a half to two hours. 
Before meals and shortly afterward patient feels well. Appetite 
very good. 

Present Condition. — Patient looks somewhat pale. Tongue 
clear, with but a slight coating at the back. Gastric region not 
painful to pressure; stomach not enlarged. 

One hour after the test breakfast: HC1 + ; acidity =100; 
free HC1 = 88; dextrin + traces; erythrodextrin+very much. 

In the fasting condition, the stomach is empty. 

The following represents an atypical case of hyperchlor- 
hydria: 

Patient (M. A ) has been ailing for four or five years with 

pains in the stomach and frequent vomiting. Sometimes she 
has no pains for two to three weeks, at the end of which time 
they reappear. The pains occur immediately after meals. She 
also vomits large quantities of food. On examination I found 
that the stomach was only sensitive to pressure; otherwise 
nothing could be discovered. With regard to diagnosis it was 
questionable whether I had to deal with an ulcer or with some 
functional disorder of the stomach. The regular treatment for 
ulcer (milk diet, rest, large doses of bismuth) was instituted, but 



320 DISEASES OF THE STOMACH. 

after a period of three weeks the symptoms had not abated. 
The pains appeared in the same severity and the vomiting per- 
sisted. The failure of the treatment made it probable that there 
was no ulcer. Patient was examined one hour after a test 
breakfast, and the following condition found: HC1 + ; acidity = 
100; free HC1=86. In the fasting condition the stomach was 
empty. Hyperchlorhydria was diagnosed, and the treatment ar- 
ranged accordingly. The patient now rallied very quickly and 
recovered entirely. 

Prognosis. — The prognosis in hyperchlorhydria is, as a rule, 
quite good, except in some cases of a very protracted and severe 
nature, in which, the prognosis regarding the complete disap- 
pearance of this condition is bad, although even then there is 
no danger of a fatal issue. 

Diagnosis. — The diagnosis of hyperchlorhydria is made either 
from the subjective symptoms alone or from these in connection 
with the results of a chemical examination of the gastric con- 
tents. The subjective symptoms characteristic of hyperchlor- 
hydria are: 

1. Pain, appearing constantly about two to three hours after 
meals. Relief from the pain is felt immediately after the inges- 
tion of an alkali, or a little while after the partaking of some 
food, especially albuminous. 

2. Appetite and thirst are either in a healthy condition or 
increased. 

3. No marked cachexia. 

4. Constipation. 

Although all the symptoms mentioned make the diagnosis of 
hyperchlorhydria probable, it can be made with certainty only 
after repeated examinations of the gastric juice. 

1. On examination of the stomach in the fasting condition, 
the organ is either found empty, or contains only a few cubic 
centimetres of juice. 

2. One hour after Ewald's test breakfast the degree of acidity 



HYPERCHLORHYDRIA. 327 

is found greatly increased, owing to the large amount of free 
hydrochloric acid. 

Differential Diagnosis. — In making the diagnosis of hyper- 
chlorhydria, we shall have to exclude all conditions which are 
liable to give similar symptoms; for instance, gastric ulcer, 
permanent hypersecretion, and biliary colic. The characteris- 
tic symptoms of ulcer have been described above, and w T e shall 
here limit ourselves to the remark that the pain of an ulcer, 
even if this is accompanied by hyperchlorhydria, does not dis- 
appear entirely after the ingestion of large doses of alkalies. 
Permanent hypersecretion is very frequently accompanied by 
vomiting, and the most intense attacks of gastric pain appear, 
as a rule, in the middle of the night or early in the morning. 
On examination with the tube, the stomach in the fasting 
condition is found to contain considerable quantities of gastric 
juice (80 to 100 c.c). Biliary colic, not accompanied by 
jaundice or by a considerable palpable swelling of the gall 
bladder, may give rise to errors as to the real cause of the pain. 
In biliary colic, however, the pains, as a rule, appear later than 
in hyperchlorhydria (four to five hours after a meal), and are 
not eased by the ingestion of food or by alkalies. Another 
means of differential diagnosis is that the pains in biliary colic 
most commonly extend over the right epigastric and hypo- 
chondriac regions, whereas the pains of hyperchlorhydria are 
felt more in the middle of the epigastrium, although sometimes 
radiating farther to the right. ' 

Treatment. — Hygienic Regimen. — In view of the fact that 
hyperchlorhydria is most frequently caused by too much mental 
work, the daily life of the patient as to amount of work, bodily 
exercise, mental rest, and pleasure must be regulated. With 
I to this point, the same rules will not apply to all, but it 
will be necessary to individualize each case for itself. Thus 
business men with a <rreat deal of responsibility resting upon 
them, lawyers, politicians, and physicians must be sent away 



328 DISEASES OF THE STOMACH. 

from their work to some country place, so as to relieve their 
brains temporarily from the strain. Ladies moving in high 
social circles, and participating in all manner of festivities, will 
have to be restricted to a more quiet life. Again, there are 
people with large fortunes and without any occupation what- 
ever, who become sick from paying too much attention to their 
own bodily functions. Here it will be necessary to occupy the 
mind of these patients with some kind of work. 

Cold sponge baths in the morning, bodily exercise of about 
eight to ten minutes' duration every morning are in most 
instances of value. Walking once or twice a day for half an 
hour to an hour, horseback riding, driving, bicycle riding 
should be highly recommended. 

Diet. — All substances that are liable to excite intensely the 
glands of the stomach must be excluded from the dietary of 
such patients. Therefore all kinds of acids, including organic 
acids (citric, tartaric, acetic acid); all kinds of spices, such as 
pepper, mustard, horseradish, and the like, must be forbidden. 
The food should consist of material rich in albumen, while the 
quantity of starchy substances should be diminished. Thus 
all kinds of meat (even game), fish, oysters, eggs, milk, should 
be taken in large quantities. Bread and butter are permitted. 
Potatoes, spinach, asparagus, green peas, farina, and rice 
should be taken only in small amounts. Whiskey and wines 
should, as a rule, be avoided. Cacao, weak tea, weak coffee, 
and beer can be given in moderate quantities. The use of 
tobacco should be restricted. 

As a rule, it is advisable to have the patient partake of five 
or six meals daily, three heavy and two or three lighter ones. 
The heavier meals should not deviate much from the ordinary 
bill of fare, while the lighter meals should consist either of a 
glassful of milk or zoolak, with bread and butter or a cup of 
cocoa and a few crackers, or occasionally a cup of bouillon with 
an egg beaten up in it, and some bread, or half a dozen oysters, 



HYPERCHLORHYDRIA. 329 

a few crackers, and a glass of beer. The patient must be im- 
pressed with the importance of thoroughly masticating the food 
and eating slowly, besides resting fifteen to twenty minutes 
after each meal. 

Outline of Diet in Hyperchlorhydria. 



Calories 

7:30 a.m., two eggs 160 

wheaten bread, 50 gni., 128 

butter, 20 gm., 1 63 

milk. 250 gm., 169 

10:30 a.m., zoolak or milk, 200 gm., 135 

crackers or bread, 30 gm., 77 

butter, 10 gm., 81 

1 p.m., broiled meat, 100 gm., 210 

mashed potatoes, 50 gm , 63 

bread, 30 gm., 77 

butter, 10 gm., 81 

weak tea or Vichy water, 200 gm. 

3:30 p.m., The same as at 10:30 a.m., 293 

6:30 p.m., soup (with barley or vermicelli), 200 gm., 100 

bread and butter (bread, 30 gm.; butter, 10 gm.), .... 158 

meat (broiled or cooked), 100 gm., 210 

potatoes, baked, 50 gm., 60 

green vegetables (spinach, green peas), 50 gm., 80 

coffee (half milk), 100 gm., 34 

10 p.m., oysters and crackers, or cold meat sandwich, one glass of beer, 260 

2,539 

Medicaments. — All kinds of alkalies can be used in the 
treatment of this affection. Where hyperchlorhydria is not 
complicated with constipation, bicarbonate of soda may be 
given, either alone or in combination with sugar of milk or 
peppermint sugar (German Pharmacopoeia), in doses of half a 
teaspoonful to about one teaspoonful three times a day, two 
hours after meals. Calcined magnesia and magnesia ammonio- 
phosphorica neturalize four times as much acid as bicarbonate 
da. The following prescriptions are therefore very 
serviceable: 



330 DISEASES OF THE STOMACH. 

T\ Sodii bicarbon., 

Magnes. ust., aa 20.0 5 v. 

M. exactissime. F. pulv. D. ad scatulam. S. Half a teaspoonful to a 
teaspoonful three times daily, two hours after meals. 

Or, 

1^ Sodii bicarbon., 20.0 5 v. 

Magnes. ust., 

Magnes. ammonio phosph., aa 10.0 3iiss. 

M. exactissime. F. pulv. D. ad scatulam. S. Half a teaspoonful to a 
teaspoonful three times daily, two hours after meals. 

In cases which are accompanied by constipation, magnesia 
usta and some rhubarb can be added, and here I frequently 
prescribe the following: 

I^ Magnes. ust., 

Pulv. rad. rhei, aa. 7.5 5 ij- 

Sodii carbon, exsiccat., . 
Sodii bicarbon., 

Elaeosacch. menth. pip., aa. 15.0 oiv. 

M. exactissime. F. pulv. D. ad scatulam. S. Half a teaspoonful to a 
teaspoonful three times daily, two hours after meals, to be taken in plain 
water or in Vichy water. 

Bouveret uses sodium bicarbonate in 2 gm. doses, to be taken 
two hours after lunch and after supper, and to be repeated 
after an hour's interval. The alkaline treatment can be con- 
tinued for very long periods without any ill effects whatever. 
In cases in which the nervous element is more disturbed (sleep- 
lessness, headaches, over-excitability, etc.), we should give a 
good dose of a bromide salt. I am in the habit of prescribing 
strontium bromide: 

1} Stront. brom. puriss., 12.0 3iij. 

Aq. menth. pip., 60.0 3xv. 

S. One teaspoonful twice daily in milk at mealtime. 

Sodium bromide and ammonium bromide can be employed in 
the same way. The bromides should, however, be given only 
for a week or two, and their use then discontinued for a short 
time, after which they may be resumed for the same length 
of time. I also frequently prescribe the following: 



GASTROSrCCORRHCEA CONTINUA PERIODICA. 331 

1$ Zinc valerian 0.05 

Magnes. perliydrol (Merck) 0.2 

Xatr. bicarbon, 0.3 

D. in., caps, gelat. opert., t. d. Xo. XX. 

S. One capsule t. i. d., one hour p. c. 

Boas advises the administration of small doses of morphine or 
codeine. He frequently prescribes the following : 

R Magnes. ust., 15.0 Siijf. 

Morphinae hydrochlor., 0.1 gr. if. 

M. f. pulv. D. ad scat. S. A point of a knife to a teaspoonful three 
times daily. 

I have very seldom seen the necessity of prescribing either 
morphine or codeine in this affection. 

Of the watering-places, Vichy and Neuenahr are to be highly 
recommended. For the treatment of these patients at home 
these mineral waters are taken most advantageously in small 
quantities. 

Electricity. — In cases of a protracted nature, the direct appli- 
cation of the electric current to the inside of the stomach is 
frequently of the greatest benefit. In most instances the 
faradic current should be applied, but in cases in which the 
pains are very severe galvanization should be employed. As 
to the mode of application of the current and the length of 
time required for this treatment, see the section on electricity. 
The electric current applied in this manner exerts a stimulating 
tonic influence, not only upon the stomach, but also upon the 
small and large intestines. I have frequently seen cases of 
hyperchlorhydria, accompanied by the most obstinate consti- 
pation, perfectly cured by means of the current, even when 
no drugs whatever had been given. 

Ga&trosuccorrkcea Continua Periodica (Reichmann) . 

onyms. — Gastroxynsis (Rossbach); periodic continuous 
flow of gastric juice. 



332 DISEASES OF THE STOMACH. 

Definition. — Gastrosuccorrhcea continua periodica is a condi- 
tion characterized by the acute appearance of a constant secre- 
tion of a gastric juice giving rise to attacks of vomiting and 
severe pains. 

General Remarks. — Organic affections of the peripheral or 
central nervous system are present in some cases of this dis- 
order, although it may occur in persons who are apparently 
free from nervous troubles. Reichmann 1 was the first to call 
attention to the periodic continuous flow of gastric juice; a 
few years previously Rossbach 2 had described under the name 
of gastroxynsis a nervous affection of the stomach, which con- 
sists in a sudden appearance of sever headaches accompanied 
by gastric pains and vomiting of very acid chyme or gastric 
juice. In accordance with Boas, I consider gastroxynsis and 
gastrosuccorrhoea continua periodica to be one and the same 
affection, and do not think they should be treated under 
different headings. 

Symptomatology. — In the midst of perfect health a sensation 
of discomfort is experienced in the gastric region, which is 
associated with restlessness. Soon afterward the discomfort 
changes into a rather painful sensation, and nausea appears. 
The patient is compelled to occupy a recumbent position. 
The symptoms just described continue or rather increase in 
severity, and in about an hour or two the nausea ends in vomit- 
ing of a large quantity of gastric contents. The patient may 
now feel a little relieved for a short time, but soon the same 
symptoms return. The appetite is entirely lost and instead 
there is extreme thirst. The more the patient drinks the 
more, as a rule, he has to vomit. If he abstains from drink- 
ing, the vomiting is less frequent, but persists nevertheless. 
Thus, as a rule, in the middle of the night or early in the morn- 
ing, the patient has to vomit a large quantity of a watery 

1 Reichmann: Berl. klin. Wochenschr., 1882, No. 40. 

2 Rossbach: Deutsch. Arch. f. klin. Med., 1885, Bd. 35. 



GASTROSUCCORRHCEA COXTIXUA PERIODICA. 333 

liquid which is very acid in character, and either quite clear 
or greenish from the admixture of bile. If this liquid be 
examined it will be found that free hydrochloric acid is present 
in large quantities, as are the ferments (rennet and pepsin). 
No food particles can be discovered in the fluid. It consists 
of either clear gastric juice or gastric juice with admixture of 
a little bile. After such an attack frequently a constant 
desire to vomit persists, and the patient suffers from very violent 
and painful retelling. Often a quarter of an hour after the 
last paroxysm, the patient's efforts to vomit cause a small 
quantity of yellow bile to be ejected. Even if the patient 
absolutely abstains from all kinds of food and drink, a few 
hours later a large quantity of gastric juice may again be 
vomited. The patient in this condition is hardly able to sleep 
for any length of time, as the pain awakens him soon after he 
has fallen asleep. 

The abdomen, as a rule, is sunken. The patient looks ex- 
tremely pale, and his extremities are frequently cold. Severe 

aches often accompany this train of symptoms, and con- 
stipation is almost a constant concomitant. After this con- 
dition has lasted for two or three days, or sometimes even 
longer, the nauseous feeling begins to disappear, the pains 
subside, and the patient experiences for the first time a desire 
for food. He is now able to eat without vomiting, and in a 
day or two feels like himself again. It is characteristic of 

-flection that the symptoms disappear almost suddenly, 
and that the patient who seemed to be in a wretched state a 
few hours before may now appear nearly well. 

After a period of perfect euphoria, varying from several 
weeks to a few months or a year or even longer, a similar attack 
may occur. The attacks may than either recur after the same 
period of time, or the intermissions of health may become 
gradually shorter, SO that ultimately the patient has hardly 
recuperated from his last attack before a new one supervenes. 



;m DISEASES OF THE STOMACH. 

The latter condition forms the intermediary stage between 
periodic and chronic gastrosuccorrhcea. 

During the free intervals the gastric secretion takes place 
either in a perfectly normal manner or hyperchlorhydria may 
exist. In either case, however, the stomach remains free from 
secretion in its empty state. 

The following cases may serve as good illustrations of this 
affection: 

Case I. — R. B. I , aged 37, business man. During 1890 

and 1891 patient had several attacks of the then prevailing 
grippe. In December, 1892, after the third attack of the grippe, 
he was taken ill with a stomach trouble, the nature of which pa- 
tient describes as follows: "I was seized suddenly with a fit of 
vomiting, entirely emptying the stomach apparently, but 
followed by successive spells, at an interval of one to two hours, 
accompanied by the most intense pain. This would last from 
twenty-four to thirty-six hours, and sometimes forty-eight, after 
which the stomach would gradually quiet down so that nourish- 
ment in the form of milk — either hot milk or kumyss — could be 
taken in small quantities at intervals of about two hours, until a 
normal condition was restored, which usually took from two to 
three days to accomplish. 

"The character of the vomit was, first, that of undigested food, 
followed by a strong and very acid fluid of a whitish, and finally 
of a greenish color, consisting principally of bile. After each of 
the spells mentioned the intense pain would subside, and I would 
fall asleep — to be awakened again by a recurrence of the pain — 
the intervals of sleep and suffering varying from an hour to 
three as I became better, and continued until vomiting had 
ceased. 

" During all these spells I was exceedingly nervous — the 
slightest noise or vibration causing pain and sometimes causing 
the vomiting. General condition after becoming able to sit 
up was one of extreme weakness — having lost from ten to twenty 
pounds, as the attacks were longer or shorter. 

" During 1893 I was ill four or five times, in 1894 as often, and 
in 1895 four times. Weight previous to grippe averaged 135 



GASTROSUCCORRHCEA CONTINUA PERIODICA. 335 

to 138 pounds; since these attacks it has varied from 125 to 133." 

Present Condition. — July 22d, 1895. — Chest organs normal. 
The palpation of the abdomen does not reveal any pathological 
condition. The splashing sound can be easily produced in the 
gastric region, and extends downward to about two fingers' width 
below the navel. Knee reflex present. Urine does not contain 
any sugar or albumin. Besides the above-described attacks of 
vomiting, patient complains of a feeling of heaviness in his 
gastric region about one hour after meals, and of slight consti- 
pation. 

July 23d. — Examination of the gastric contents one hour 
after kwald's test breakfast: HC1 + , acidity = 100, free HC1 = 86. 

October 8th. — Patient is in bed suffering from one of the 
attacks mentioned; he has vomited several times during the day 
and is suffering from intense pain. On inspection the abdomen 
is slightly sunken; on palpation the whole gastric region is found 
extremely sensitive and painful to pressure. The hands and also 
the face (particularly nose and forehead) are somewhat cold; 
pulse, 110; temperature, 98° F. The vomited matter consists of 
a pretty clear fluid with an abundant admixture of mucus; no 
food particles can be discovered in the liquid. On chemical 
examination free HC1 as well as pepsin and rennet are found 
present in large amount. Patient complains of intense thirst. 
Under the administration of opiates he grew better and was able 
to leave his bed after three days. 

Case II. — George N. J , 42 years of age, merchant, suffered 

for five years from frequently appearing attacks of pains in the 
o of the stomach. These attacks were usually accompanied 
by vomiting of highly acid substances; they recurred once every 
three to four weeks and lasted about three days. During the 
attack the patient felt miserable and down-hearted, suffered 
from severe pains; was not able to eat anything and vomited 
frequently. When the attack was over he felt perfectly well, 
pt that his sleep was somewhat disturbed. 

The physical examination shows: Chest and abdominal organs 
flex present; stomach not dilated (the site 
of the stomach having been determined by gastro-diaphany). 

gust 31st, 1891.— One hour after test breakfast, HC1 + , 
acidity = I 

The patient was directly gastro-faradized for a period of two 



336 DISEASES OF THE STOMACH. 

months. He had no attack during the time of treatment, nor 
any thus far after it was discontinued; sleeps well and feels 
stronger and full of life. 



Diagnosis. — The diagnosis of gastrosuccorrho?a continua 
periodica can be made by the above-described symptoms, in 
connection with the examination of the vomited matter (which 
is found to consist principally of clear gastric juice without 
admixture of much food), or with the examination of the 
stomach in the fasting condition by means of the tube (which 
results in the withdrawal of a considerable quantity of clear 
gastric juice). Inasmuch as similar attacks of gastrosuccor- 
rhcea may occur as a consequence of either an open ulcer or a 
cicatrix within the stomach, the pylorus, or the duodenum, 
it will be necessary to exclude such organic affections before 
making a diagnosis of continuous periodic gastric flow, which 
we consider to be a nervous affection. It will also be of 
importance to exclude organic spinal or cerebral troubles, 
which may cause a similar disorder of reflex origin. 

Prognosis. — The prognosis of pure gastrosuccorrhoea continua 
periodica is, as a rule, not bad. In many instances it is possible 
either to make the attacks less severe, or in some instances 
to effect a cure by rational treatment. 

Treatment. — It will also be advisable to analyze the gastric 
juice of the patient during the free intervals. If hyperchlor- 
hydria is found this will have to be treated (see p. 327), even 
if there should be no subjective complaints; for hyperchlor- 
hydria is frequently, although not always, the cause of such 
attacks. At any rate, a hygienic way of living should be inaugu- 
rated by the physician. I am in the habit of prescribing a good- 
sized dose of bromide as soon as the patient feels an attack 
coming on, and find that occasionally it may be cut short at 
the very beginning. In some instances the attack, although 
not interrupted in its progress, is thereby rendered less severe. 



GASTROSUCCORRHCEA CONTINUA CHROXICA. 337 

When the attack has appeared the patient must be kept in 
bed. A hot-water bag is placed over the gastric region, and 
if the pains are severe an opiate, either alone or in combi- 
nation with belladonna, is administered. During the first day 
of the attack no nourishment whatever should be given. A 
teaspoonful of cold water or a small ice pill can be administered 
from time to time, especially if the patient is very thirsty. 
The next da}* small quantities of milk, matzoon, or egg water, 
one or two tablespoonfuls, are given every hour. On the third 
day the quantity of nourishment may be increased to half a 
cupful at a time administered every two hours, and besides 
the above liquid food the white of a hard-boiled egg chopped 
up fine may also be given (one or two eggs a day). On the 
fourth day meat (scraped, raw, or broiled) may be tried, and 
afterward the diet gradually arranged as for cases of hyper- 
chlorhydria. The system of diet as laid down here for every 
day from the beginning of the attack will certainly depend 
upon the condition of the patient, and will have to be modified 
accordingly. As there is always constipation during the 
attack, it will be best to move the bowels on the second or 
third day, either by a glycerin suppository or by a large injec- 
tion of water (a quart of water and a teaspoonful of salt), or an 
injection of sweet oil (one pint). 

Gastrosuccorrhoea Continua Chronica (Reichmann) . 

onyms. — Chronic continuous flow of gastric juice; Reich- 
mann".- disease. 

Definition. — Reichmann, 1 in 1882, described under the above 

name a disorder which is characterized by a constant secretion 

stric juice, even in the absence of food in the stomach. 

Considerable quantities of gastric juice can be withdrawn from 

the stomach in the morning, even in the fasting condition. 

>hmann: BerL klin. Wochenschr., 1882, No. 40; 1884, No. 48, and 
1887 No. 12. 
22 



33S DISEASES OF THE STOMACH. 

General Remarks. — In describing this new disease Reichmann 
in 1887 mentioned that he had observed sixteen cases. An 
exact scientific diagnosis had been made, however, only in six 
of them. "In the remaining cases," says Reichmann, "I was 
able to find in the stomach in the morning in the fasting con- 
dition a large quantity of a liquid containing hydrochloric acid 
and no pepsin, and exhibiting digestive properties, but also 
containing much peptone and remnants of amylaceous food." 

Among the six cases which Reichmann considered as typical 
of gastrosuccorrhcea chronica, I think that only one (Case 3) 
deserves this name, for the remaining five, aside from the con- 
stant secretion of gastric juice, presented other important 
lesions of the stomach, which in all probability were rather the 
cause than the effect of the constant gastric flow. In all the 
cases described by Reichmann, except in Case 3, the stomach 
in the fasting condition contained a considerable quantity of 
liquid, consisting of gastric juice, and containing only amyla- 
ceous food remnants. When the stomach had been washed 
out on the previous night, and the patient had abstained from 
food or drink, the stomach in the morning nevertheless con- 
tained clear gastric juice. These cases are then undoubtedly 
cases of dilatation of the stomach, or, more correctly speaking, 
of stenosis of the pylorus, in which hypersecretion must 
be considered as a concomitant factor. Reichmann, and fol- 
lowing him, especially the French writers Bouveret, 1 Debove 
and Remond, 2 and among the Germans Riegel, 3 have laid too 
little stress upon the distinction between the constant flow of 
gastric juice and dilatation of the stomach due to stenosis of 
the pylorus. On this account the picture given by these 
authors of the true gastrosuccorrhcea chronica bears a closer 
resemblance in many points to that of dilatation of the stomach 

1 Bouveret: "Traite des Maladies de l'Estomac." 

2 Debove et Remond: "Les Maladies de l'Estomac." 

3 Riegel : Deutsche med. Wochenschrift, 1893, Nos. 31 und 32. 



GASTROSUCCORRHCEA COXTIXUA CHRONICA. 339 

than to the picture of the affection in question. Inasmuch as 
the treatment of cases of stenosis of the pylorus is in most 
essential points different from cases of gastrosuccorrhoea (I 
need only mention that the most rational treatment for the 
former is a surgical one), it is absolutely necessary strictly to 
differentiate between these two conditions. 

Eighteen years ago Schreiber, 1 of Konigsberg, published an 
extensive paper in which he expressed doubt as to the existence 
of the new disease, regarding all the cases described by Reich- 
raann as cases of dilatation of the stomach with stagnation of 
food. Shortly afterward two other important papers appeared 
with reference to this question. Riegel defended Reichmann's 
views, while Martius 2 was inclined to favor Schreiber's opinion. 
Whether Schreiber's view, that the stomach normally secretes 
gastric juice even while in its empty state, is correct or not, is a 
question that is quite difficult to decide, although I am person- 
ally of the opinion that when there is no food in the stomach 
there is no secretion. But leaving aside this question about 
the physiology of the stomach, there is no doubt that, as a 
rule, the stomach in the fasting condition does not contain any 
considerable quantity of gastric juice. Whenever larger 
quantities are found the stomach must be regarded as affected. 

Etiology. — Gastrosuccorrhoea chronica is met with much more 
frequently in men than in women. In some instances there is 
present besides this affection some other functional neurotic dis- 
turbance. In three of my cases the latter was very marked. 
Thus one of these patients complained of a burning sensation 
all over his limbs, which lasted for three months and then sud- 
denly disappeared. Like hyperchlorhydria, gastrosuccorrhcjea 
seems to arise from great mental worry or strain. 

iptomatology. — After a more or less prolonged period of 
different dyspeptic disturbances which are similar in character 

Deutsche med. Wbchenschr., 1893, Nbs. 20 und 30. 
'Martius: Deutsche mod. Wochenschrift, 1894. 



340 DISEASES OF THE STOMACH. 

to those caused by hyperchlorhydria, there appears a pro- 
nounced sensation of pain several hours after and shortly before 
meals. Very soon vomiting supervenes as a new symptom. 
At first it occurs only occasionally, but constantly grows more 
frequent until at last there may be one or several vomiting 
spells every day. The vomiting appears most frequently soon 
after breakfast, sometimes also after supper. In only a few 
cases does it occur in the night, about two or three o'clock, 
preceded by a long and severe attack of pain. The vomited 
matter is always very acid and more or less liquid. The night 
vomit consists, as a rule, of a clear liquid containing hardly 
any food. 

The appetite is generally increased, although there are excep- 
tions to this rule. In some cases periods of extreme hunger 
alternate with periods of pronounced anorexia. In most cases 
the sensation of thirst is greatly increased. In all of my cases 
constipation was marked. In some there was loss of weight, 
but none of my patients was emaciated in any great 
degree. 

Diagnosis. — Although the symptoms described might suggest 
the presence of gastrosuccorrhcea in certain cases, the exact 
diagnosis can be made only by a repeated examination of the 
stomach in the fasting condition. By inserting the tube into 
the stomach, and telling the patient to exert some pressure with 
his abdominal muscles, more or less liquid (60 to 100 c.c.) is 
obtained from the stomach. This contains no food particles, 
but exhibits all the properties of the gastric juice. It may 
look greenish from the admixture of bile, but this is not an 
important sign. The filtrate, as a rule, shows a somewhat 
increased degree of acidity. It never contains any starchy 
products (absence of erythrodextrin, achroodextrin, and sugar) . 

Microscopically no sarcinse or other signs of decomposition are 
found. Frequently cell nuclei are met with in large numbers. 
In examining the patient one hour after Ewald's test breakfast, 



GASTROSUCCORRHCEA CONTINUA CHRONICA. 341 

the gastric contents will be found to contain more liquid than 
usually, and the degree of acidity will be quite high (80 to 120.) 
As a rule, the degree of acidity of the gastric contents is higher 
than that of the gastric juice when withdrawn from the stomach 
in the fasting condition. In examining the filtrate of the gastric 
contents with reference to the starchy products, it will be found 
that the Lugol solution will produce a deep violet or even blue 
color, showing that the starch has not been much changed. A 
thin disc of hard-boiled egg will be digested in the filtrate at 
blood temperature in about half an hour to an hour. The dif- 
ference as to the degrees of digestion of the albuminates and 
starches (the former being more quickly, the latter much more 
slowly digested) can be best studied after Leube-RiegeFs test 
dinner. Three to four hours after such a dinner the obtained 
gastric contents show hardly any meat particles whatever (all 
being digested), whereas particles of starchy food form the 
principal part of the mixture. In this way the difference 
between the digestion of meats and starchy foods existing in 
this affection is seen at once. 

Differential Diagnosis. — In making the diagnosis of gastro- 

succorrhcea, all organic lesions of the stomach (ulcer and 

stenosis of the pylorus) which are liable to be accompanied 

with gastrosuccorrhcea will have to be excluded. According 

to my experience, it is easy to exclude stenosis of the pylorus, 

but not an ulcer. In stenosis of the pylorus the stomach in the 

fasting condition is also found to contain a liquid, but this is 

mixed with food and the filtrate always shows the presence of 

Btarch or sugar products. But the main thing is that food 

particles can be seen even with the naked eye, whereas the liquid 

found in the stomach in rase of genuine gastrosuccorrhcea does 

'>ntain any food particles, as described above. The pres- 

of an ulcer will be suspected if there has been a preceding 

haematemesifi or melsena or a circumscribed spot in the gastric 

. very painful to the slightest pressure. The absence of 



342 DISEASES OF THE STOMACH. 

these symptoms will tend to justify the diagnosis of gastro- 
succorrhoea. 

In this respect I agree with Reichmann as to the existence 
of a pathological continuous gastric succorrhcea, although I 
restrict this name to cases not presenting any organic lesions 
of the stomach. Whenever the latter exist, I deem it best 
to look upon the accompanying gastric succorrhcea as a conse- 
quence of the main trouble, but not as the cause of the organic 
lesion. According to my experience, which coincides with that 
of Ewald, cases of genuine gastrosuccorrhcea chronica are quite 
rare. They are less frequent than those of periodic gastro- 
succorrhcea. During the last eight years I have met with eight 
cases of this affection, one of which I 1 published in 1887. The 
following is the description of one of my recently observed 
typical cases of gastrosuccorrhcea. 

A. S , 21 years old, has suffered since early youth from 

digestive troubles. As far back as he can remember, he has 
felt hungry very soon after meals (one hour). The bowels, al- 
though usually regular, were at times very constipated. Patient 
was always weakly, but in the last three years he has been troubled 
to a much greater degree. He felt extremely weak, became 
dizzy after meals, and was overcome by a feeling of sleepiness. 
The bowels became constipated all the time. During the last 
six or seven months there was a sensation of extreme weakness in 
the hands and feet. The appetite was constantly increased, and 
a hungry feeling appeared very frequently. For the past three 
months there had been a burning sensation in the gastric region, 
which increased in severity about an hour or two after meals. 
From that time on the patient began to vomit frequently. The 
vomiting, as a rule, occurred very soon after a meal, although 
occasionally it took place either in the middle of the night or in 
the morning before breakfast. Patient had lost lately in weight 
(about ten pounds). 

Present Condition. — Chest organs intact. On palpation, the 
gastric region is somewhat sensitive to pressure. There is, how- 

1 Max Einhorn: New Yorker medicinische Presse, 1387. 



GASTROSUCCORRHGEA CONTINUA CHRONICA. 343 

ever, no circumscribed painful area. A splashing sound can be 
produced extending to about one finger's width above the navel. 
The tongue is thickly coated. The color of the lips and cheeks is 
quite good, and the patient does not look emaciated. The knee 
reflex is present, and the urine does not contain anything abnor- 
mal. The examination of the stomach one hour after a test 
breakfast showed the quantity of chyme to be small (about 30 
c.c); hydrochloric acid + , acidity = 100. 

The examination of the stomach in the fasting condition re- 
vealed the presence of a considerable quantity of pure gastric 
juice; 120 c.c. of a somewhat turbid liquid, not containing any 
food remnants whatever, were withdrawn with the tube. This 
fluid contained free hydrochloric acid, had an acidity of 80, gave 
only weak biuret reaction, while erythrodextrin, dextrin, and 
sugar were wholly absent. During the first three months of 
treatment the condition of the stomach in reference to its secre- 
tion of juice did not change in any way. Repeated examinations, 
which had been made in the fasting condition of the patient, al- 
ways gave the same result: presence of about 100 c.c. or more of 
pure gastric juice. 

The treatment consisted at first in regulation of the diet, and 
in the administration of large doses of alkalies. Later on wash- 
ing of the stomach and spraying of the organ with a 1 to 2:1,000 
solution of nitrate of silver was instituted. The latter means 
proved more effective than the former treatment, and after about 
two weeks it was noticed that the stomach in the fasting condi- 
tion contained considerably smaller quantities of juice. Fre- 
quently but 30 or 20 c.c. of juice were found. The spraying was 
continued for two months, after which time the stomach in the 
fasting condition was usually found empty. This objective 
improvement was connected with a subjective amelioration of 
all the symptoms: the vomiting ceased, the hunger was much 
marked, the dizziness subsided, and the patient felt stronger 
and could do his work much better. The examination of the 
stomach one hour after the test breakfast, however, showed that 
the hyperchlorhydria still persisted. In this case we frequently 
tried to determine the motor (transportation) faculty of the 
stomarh. One and a half hours after Ewald's test breakfast, as 
a rule, the stomach was found empty, showing that this faculty 
;tther increased. This is of interest, inasmuch as it shows 



344 DISEASES OF THE STOMACH. 

that continuous hypersecretion need not be associated with 
sluggishness in the muscular action of the organ, a theory which 
is accepted by most investigators who have written on the 
subject. 

The following is another typical case of continuous hyper- 
secretion : 

S , 46 years old, has been suffering from digestive disturb- 
ances since 1893. The principal symptoms consist in pains 
appearing in the gastric region about three hours after meals 
and also early in the morning before arising. The appetite was 
always good. Thirst is frequently greatly marked and with it a 
sensation of dryness in the mouth. 

The pains are almost always relieved either by food or by 
bicarbonate of soda. Steady brain work, strain in business, and 
worry greatly aggravate the condition, while a stay in the country 
and rest materially diminish the symptoms. There were several 
intermissions of the symptoms extending over a period of a few 
months' duration. But thus far they have always returned. 
Constipation exists in a high degree. 

On examination the stomach is found to extend to two fingers' 
width below the navel; the gastric region is not painful to pres- 
sure. 

One hour after test breakfast: Quantity of chyme (consist- 
ing of fine pieces of roll and a watery liquid) amounts to 500 c.c. 
HC1 + , acidity = 108, free HC1 = 92, erythrodextrin + much. 

In the fasting condition, the stomach contains 130 c.c. of a 
watery liquid not mixed with any particles of food. HC1 + , 
acidity = 100, free HC1 = 90, erythrodextrin = 0. 

Several other examinations gave similar results, and for quite 
a while the stomach in the fasting condition usually contained 
from 70 to 140 c.c. of clear gastric juice. The treatment consisted 
in the application of intragastric galvanization and spraying with 
nitrate of silver. The symptoms gradually subsided. 

Prognosis. — According to my experience, the prognosis of 
gastrosuccorrhcEa is not bad. As a rule, most patients improve 
under rational treatment. Frequently, however, there are 



GASTROSUCCORRHCEA CONTINUA CHRONICA. 345 

relapses. Some very obstinate cases are occasionally met with, 
and the trouble, although yielding somewhat to treatment, may 
persist for years. There is, however, no danger of a fatal issue 
resulting from this disease alone. 

Treatment. — As we have seen, gastrosuccorrhcea is always 
associated with hyperchlorhydria. The treatment of the latter 
condition in reference to diet, drugs, and mode of living will 
have to be resorted to here also. With reference to diet, I have 
only to add that it is of great importance not to permit the 
patient to partake of any large quantities of liquid. In this 
affection more stress must be laid upon this point than in 
hyperchlorhydria. 

Medicaments. — The treatment of gastrosuccorrhcea must be 
directed toward decreasing the undue amount of gastric secre- 
tion. With this end in view, Voinovitch 1 recommends the use 
of atropine in doses of 2 mgm. (gr. -j^) daily. Bouveret prefers 
morphine to atropine. Following the advice of Leubuscher 
and Schaeffeiy he administered as much as 2 to 3cgm. (gr. 
|-J) of sulphate of morphine three times daily by subcutaneous 
injection. This author doubts, however, whether this treat- 
ment, which seems to be effective in the initial state of the 
affection, will prove useful in cases that have progressed 
further. The use of either atropine or morphine may be tried 
for a short time, but they should never be administered for a 
period. The subcutaneous injections of morphine especi- 
ally should be avoided, as the patient runs the risk of becoming 
an hahitiir of this drug. 

La: _ - of subnitrate of bismuth (2 gm. or half a drachm 

in a wineglassful of water three times daily half an hour before 
'•in to have occasionally very good effects. Wolff 3 
mmendfl Carlsbad salt or 

1 Voinovitch: La Semaine meclicale, April 6th, 1802. 

2 Leubuscher and Schaeffer: Deutsche med. Wochenschr., 1S92. 
8 Wolff: Zeitaehrift f. Idin. Med., Bd. xvi. 



346 DISEASES OF THE STOMACH. 

1} Sod. sulph., 30.0 

Potass, sulph., 5.0 

Sod. chlorat., 30.0 

Sod. carbon., 25.0 

Sod. bicarbon., 10.0 

M. f. pulv. Half a teaspoonful in half a glassful of lukewarm water three 
times daily: the first portion to be taken in the fasting condition, the second 
two hours before the midday meal, and the third two hours before supper. 

Riegel 1 likewise speaks highly of this mode of treatment. 

Lavage. — Reichmann, and later Riegel, recommend the use of 
lavage of the stomach as the best means of improving its con- 
dition. While Riegel washes out the stomach in the evening 
six to seven hours after the heavy meal, Reichmann and 
most writers administer the lavage in the fasting condition. 
The latter way is also employed by myself; it has the advantage 
that, by emptying the stomach in the fasting condition, we 
are better enabled to judge of the quantity of juice present, at 
a time when normally there should be none; and also that no 
food whatever is removed from the stomach. 

Instead of lavage Boas recommends emptying the stomach 
by means of a tube in the fasting condition (expression method). 

In order to combat more effectively the undue secretion, 
Reichmann recommends adding nitrate of silver to the water 
used in washing out the stomach. After it has been washed 
out with plain water, 300 c.c. of a 1 or 2:1,000 solution of 
nitrate of silver is poured into the organ, and left there for 
about five minutes, when it is withdrawn by siphonage. 

Spraying the Stomach. — Instead of the latter proceeding I 
have sprayed out the stomach after washing with a 1 or 2 : 1,000 
nitrate-of-silver solution. In many cases I found this method 
of treatment of great benefit. 

Direct Galvanization. — The first of my observed cases of gas- 
trosuccorrhoca chronica was a very obstinate one, and the 
affection did not yield much to either the medicinal treatment 

1 F. Riegel: "Die Erkrankungen des Magens," Wien, 1896, p. 268. 



GASTROSUCCORRHCEA COXTTNUA CHRONICA. 347 

or to the use of lavage. I empirically tried direct galvaniza- 
tion of the organ, and after a treatment of a few weeks the 
stomach began to be empty in the morning, and has remained 
so for several years. Since then it has been my custom to 
make use of this method in this affection, and I must say that 
the result has been very gratifying. Very often I employ both 
spraying with nitrate of silver and direct galvanization, 
applying them alternately. 



CHAPTER X. 

FUNCTIONAL DISEASES WITH VARIABLE 
LESIONS.— Continued. 

Achylia Gastrica. 

Synonyms. — Atrophy of the stomach; anadenia ventriculi; 
phthisis ventriculi. 

Definition. — This term embraces a class of cases in which 
there is a permanent absence of gastric secretion. 

General Remarks. — In 1892 I 1 suggested the term "achylia 
gastrica" for those conditions in which the stomach apparently 
secretes no juice and in which clinically the diagnosis of 
"atrophy of the gastric mucosa" seems to be justifiable. In a 
paper referring to this subject I endeavored to show that cases 
of achylia gastrica and cases of pernicious anaemia ought to be 
kept strictly apart. Whereas the latter, as a rule, end fatally, 
the former do not necessarily endanger the life of the patient. 
As a proof of this view I described a case of achylia gastrica 
which I had under observation for four years and whose con- 
dition had meanwhile somewhat improved, and another case 
in which the history given by the patient made it probable 
that the stomach had persisted in this state of juicelessness 
for forty years. In this case there were no subjective symp- 
toms present and the patient used to partake of the heaviest 
food with perfect impunity. In all these cases the small 
intestine acts vicariously and completely replaces the lack of 
digestion of the stomach. 

In regard to the literature of "atrophy of the gastric mucosa" 

1 Max Einhorn: Medical Record, June 11th, 1892. 

348 



ACHYLIA GASTRICA. 349 

I refer to the excellent paper of S. Fen wick, 1 who first described 
this condition in cases of pernicious anaemia, and to the work of 
Lewy, 2 Ewald, 3 Henry and Osier, 4 Kinnicutt, 5 Nothnagel, 6 and 
George Meyer. 7 

In all cases described by these writers (mostly pernicious 
anaemia) the autopsy showed the disappearance of the gastric 
glands. Henry and Osier have given various characteristic 
drawings illustrating the microscopic picture of this condition. 

In most cases of atrophy of the stomach mentioned in litera- 
ture the sickness in question is one in which all the functions 
of the stomach are disturbed and which gradually leads to 
death. There have been described, however, a few cases of 
atrophy of the stomach in which the clinical symptoms, or, 
more correctly, the chemical analysis of the stomach contents 
led to the above diagnosis, which by no means seemed to pre- 
sent such a severe irreparable disease. In these cases no 
autopsies could be made, and atrophy of the stomach, although 
it must here be conjectured, is not as yet proven to exist. 
Cases belonging to this latter group have been described by 
Grundzach, 8 Ewald, 9 Wolff, 10 Jaworski, 11 Boas, 12 Rosenheim, 13 



S. Fenwick: "Atrophy of the Stomach." The Lancet, July, 1877. 

2 B. Lewy: Berliner klin. Wochenschr., 1887, No. 4. 

3 C. A. Ewald: ibid., 1886, No. 32. 

* Henry and Osier: American Journal of the Medical Sciences, vol. 91, 

1886, p. 498. 

5 F. P. Kinnicutt: American Journal of the Medical Sciences, vol. 94, 

1887, p. 419. 

8 Nothnagel: Deutsch. Arch. f. klin. Medicin, Bd. xxiv., Heft. 4 und 5. 

Meyer: " Zur Kenntniss der sogenannten 'Magenatrophie.'" 
rift fur klinische Medicin, Bd. xvi., p. 366. 
J. Grundzach: Berl. klin. Wochenschr., 1887, No. 30. 

\. Ewald: " [Jeber das Fehlen der freien Salzsaure im Mageninhalt." 
klin. Wochenschr., 1887, No. 30. 
L. Wolff: ibid. 
"Jaworski: Wiener medicinische Wochenschr., 1886, Nos. 49-62. 
■ I Boas: IfOnehener med. Wochenschr., 1887, Nos. 41 und 42. 
"Rosenheim: BerL klin. Wochenschr., L888, Nos. 51, 52. 



350 DISEASES OF THE STOMACH" 

Litton/ and myself. 2 For these cases the name achylia gastrica 
seems to be best adapted. 

The recent literature on cases of pure achylia gastrica (not 
complicated with pernicious anaemia) 'is not very extensive. 
Simultaneously with my article on " Achylia Gastrica" Ewald 3 
published a paper entitled: "A Case of Chronic Disability of 
Gastric Secretion (Anadenia Ventriculi?)." Ewald's views are 
in perfect accord with mine. The patient reported in the 
paper had been observed by Ewald for two and a half years. 
Although this patient improved considerably in every respect 
and gained forty-two pounds in weight, the chemical examina- 
tion of the gastric contents showed a total lack of juice. 

In this country Allen A Jones 4 has described under the name 
of "Gastric Anacidity" four cases belonging to this class of 
affections. Recently D. D. Stewart 5 has written a very 
valuable paper on the same subject. Martius and Lubarsch 6 
have just published a book on this disease. 

Morbid Anatomy. — There exist but few cases of achylia 
gastrica in which autopsies have been made. One case, 
observed by me, showed a complete atrophy of the gastric 
tubules. 

As to the question whether in all cases of achylia gastrica 
there necessarily exists an anatomical lesion (atrophy of the 
glands) or not — i.e., whether cases of achylia might not per- 
haps occur in which the gastric mucosa is not much altered, I 
must say from my own experience that the latter is frequently 

1 M. Litten und Rosengart: Zeitschr. f. klin. Medicin, 1888, p. 573. 

2 Max Einhorn : " Ein Fall von continuirlichem Magensaftfluss und ein 
Fall von vollstandigem Fehlen der Salzsaure im Magen." New Yorker 
medicinische Presse, September, 1888. 

3 Ewald: Berliner klin. Wochenschr., 1892, Nos. 20 und 27. 

4 Allen A. Jones: New York Medical Journal, May 27th, 1895, p. 573. 

6 D. D. Stewart: American Journal of the Medical Sciences, November, 
1895. 

6 F. Martius and O. Lubarsch: "Achylia gatrica, ihre Ursachen und ihre 
Folgen," Leipzig und Wicn, 1897. 



ACHYLIA GASTRICA. 



351 



the case. This is the reason why a repair of this condition is 
occasionally observed. 1 

Etiology. — According to the views generally entertained, 
achylia gastrica is a sequel to certain severe chronic catarrhal 
conditions of the stomach. The more recent text-books on 
gastric diseases (Ewald, Boas, Bouveret) discuss this affection 
under the head of ''Gastritis Glandularis Chronica." I 




' '* r »3W?gg5©5-» 



Fig. 89. — A Small Piece of Gastric Mucosa (from Patient D. S., with Achylia Gastrica) 
Found in Wash Water from Stomach. Only few glands visible; empty spaces where glands 
had previously existed; general small round-cell infiltration. X80. 



certainly believe that such an origin of achylia gastrica is 
sometimes traceable. The cases of chronic gastric catarrh in 
which the aridity is pretty low (10 to 20), and in which no 
free IIC'l exists, but both the biuret reaction and rennet are 
present . -peak in favor of this view. They represent, so to say, 



: RlaxEinhora: "A Further Report on Achylia Gastrica." Medical Rec- 
ord, July 6th, 1895. 



352 



DISEASES OF THE STOMACH. 



the prodromic stage of achylia gastrica. Notwithstanding this 
it seems to me more than probable that the affection in question 
may develop also in some other way (in consequence of nervous 
disturbances). In such instances the glandular layers of the 
stomach need not necessarily be greatly altered, although it 
appears probable that after a long persistence of inactivity of 
the glands these may begin to atrophy. 

Symptomatology. — With regard to their subjective complaints 
patients with achylia gastrica may be divided into three groups: 




Fig. 90. — A small Piece of Gastric Mucosa (from patient R. H — , with Achylia Gastrica) : 
no glands visible; a, general small round-cell infiltration; b, empty spaces where glands had 
previously existed. X80. 



1. Patients without any subjective symptoms whatever and 
enjoying perfect euphoria; 

2. Patients presenting a variety of gastric symptoms 
associated with mild intestinal disturbances; 

3. Patients without any apparent gastric symptoms, but with 
severe and obstinate intestinal disturbances. 

Cases belonging to the first group are quite rare. I therefore 
do not deem it superfluous to describe here such a case without 
any gastric or intestinal symptoms, which possesses the further 
interest that it was complicated with rumination. 



ACHYLIA GASTRICA. 353 

Achijlia Gastrica, Combined with Rumination. — August R , 



5*2 years of age, carpenter, was always well and had not consulted 
a physician for the last twenty years. Suffered in his boyhood 
from frequent headaches, cramps in the abdomen, and diarrhoea 
until his twentieth year. The patient attributes the griping 
pains in his abdomen at that time to the circumstance of growing 
up under poor and miserable surroundings; as a rule he had very 
little to eat; from time to time, however, he worked in the 
country with the peasants, where he had plenty of good things 
to eat, and here he used to overload his stomach. 

As a boy the patient partook of hardly any meat from his 
fifth to his fourteenth year of age; his main nourishment consisted 
of potatoes, flour-soup, bread, and water — soup only now and 
then; of meats he partook only when occasionally visiting his 
relatives. He did not like buttermilk or coffee. 

As long as the patient can recollect he often brought up the 
food from the stomach into the mouth about half an hour after 
the meal, chewing it and swallowing it again. AY hen eating 
cherries he was in the habit of swallowing the pits also, and after- 
ward, when bringing them up from the stomach into the mouth, 
he used to spit them out. 

This bringing up of the food the patient did mainly when feeling 
well. He enjoyed chewing the second time as much as when 
first masticating the food. Often the food would come up in 
morsels, although the patient had not been thinking of it at all. 
He hardly ever vomited, except when he got drunk — which 
happened twice during his life — and when crossing the ocean on 
a trip to Germany. He eats hastily, and the hard substances 
he chews well afterwards when they come up from the stomach. 

The patient can ruminate any time he chooses, except when 
stomach contains but very little or is almost empty. In 
ruminating he takes care to conceal the act from others; he speaks 
to no one about it, and even his wife is not aware of his habit. 

Present Condition. — Strongly built man of short stature, is 
well nourished, with good panniculus adiposus; chest organs 
: stomach dilated; the lower margin extending to one fin- 
width above the navel. He has no complaints whatever, 
enjoys a good appetite, his bowels are regular, and he feels well in 
spect. The only thing which strikes him as being 

23 



354 DISEASES OF THE STOMACH. 

abnormal, and for which he was treated for some time in Germany 
and afterward came to see me, is his coated tongue. 

October 27th. — One hour after the test breakfast: Patient 
spontaneously brings up a small quantity of the contents of his 
stomach (about 20 c.c.).. With the tube likewise only a small 
quantity can be obtained. The roll particles are not minutely 
minced and almost unchanged. HC1 = 0; acidity = 2; rennet = 0; 
propeptone = 0; peptone = 0; erythrodextrin = 0. 

Meltzer's swallowing sounds: Patient drinks water; at the 
first swallow a sound is heard immediately at the xyphoid process 
(Durchspritzgerausch) ; at the second swallow (one to two min- 
utes later) a sound in heard about eight seconds afterward 
(Durchpressgerdusch); at the third swallow the Durchspritzge- 
rausch is heard immediately; and ten seconds later the Durch- 
pressgerausch. 

I had the opportunity of examining the patient for three 
months, and always found the stomach contents in the above- 
described condition, with the same result of chemical analysis. 

The history of this case seems to indicate that the abnormal 
condition of the stomach developed in his early youth; for only 
at that time the patient had complaints, whereas later on he had 
no disease whatever. This would show clearly that achylia 
gastrica may exist forty years without endangering the vital 
functions of the organism. 

The second group, namely, of those presenting gastric symp- 
toms, comprises the greater number of cases. The symptoms 
consist of loss of appetite, of a sensation of fulness or pain in the 
epigastric and gastric regions, and of vomiting. Occasionally 
only one of these symptoms may be present, while in some cases 
the symptoms mentioned may appear alternately. Headaches 
are frequently met with, and constipation of a mild character is 
also more or less the rule. 

In some instances the symptoms are almost identical with 
those encountered in hyperchlorhydria: 1 pains one to two hours 

1 Max Einhorn : " Achylia Gastrica Simulating Hyperchlorhydria." Jacobi 
Festschrift, Xevv York, 1900. 



ACHYLIA GASTRICA. 355 

after meals, being relieved by the ingestion of food or 
drink. 

The following may be considered as a typical case of this 
group: 

Mrs. G . aged about 45, has complained of her stomach 

for the last twelve years. She is almost always troubled after 
meals with pains in the gastric and epigastric regions. Appetite 
poor. Bowels inclined to be constipated. Vomiting appears 
very seldom. Patient had lost considerably in weight during 
the first years of her ailment; thereafter her weight remained 
stationary. In 1891 she visited Carlsbad, but her condition did 
not improve any. 

Present Condition. — Patient of small stature and quite thin. 
Panniculus adiposus somewhat thin. Lips and cheeks of a pale 
color. Tongue not coated. Chest organs normal. Palpation 
of the abdomen reveals the absence of any tumor. The epigas- 
tric region is sensitive on pressure, but not exactly painful. A 
splashing sound can be produced to about three fingers' width 
below the navel. The urine does not contain either sugar or 
albumin. 

October 27th, 1892. — Examination of the stomach one hour 
after Ewald's test breakfast: HC1 = 0; lactic acid = 0; acidity 
=6; rennet =0; biuret reaction = 0; erythrodextrin = 0; sugar + . 
The quantity of the gastric contents is not large, and there is a 
very small amount of liquid. The bread particles are not 
minute. Xo mucus. 

October 30th. — When fasting, stomach empty. 

January 8th, 1893. — Examination of the stomach one hour 
after Ewald's test breakfast: HC1 = 0; lactic acid = 0; acidity = 4; 
rennet =0; pepsin = 0; biuret reaction = 0; erythrodextrin = 0; 
r-K 

During the year 1893 several other examinations of the 
gastric contents were made, with the same analytical data as 
just mentioned. 

The third group, without gastric symptoms but with intesti- 
nal disturbances, forms, according to my experience, at least 
one-fifth of all the cases of achylia gastrica. In this group 



356 DISEASES OF THE STOMACH. 

there may be either no gastric disturbances whatever or very 
slight ones (as, for instance, occasionally slight pressure in the 
gastric region — or belching). The appetite is either normal or 
somewhat increased. The principal symptom in most of these 
cases is obstinate diarrhoea, or diarrhoea alternating with periods 
of constipation. Some of these cases present symptoms similar 
to those met with in diabetes: constant thirst, frequent mictu- 
rition, extreme weakness, great loss of flesh; in some, however, 
these symptoms are less marked, or there may exist merely a 
feeling of weakness and lack of energy. 

The following case is a good representative of this group: 

Solomon S , 57^ years of age, always enjoyed good 

health until August, 1892, when he had a severe attack of dysen- 
tery; he was confined to the bed for over three weeks and felt 
afterward extraordinarily weak. Since that time the patient 
has had attacks of severe diarrhoea (much mucus, sometimes 
blood in the passages) every two to three weeks. This diarrhoea 
used to alternate with constipation. From August to October, 
1892, the patient lost forty pounds in weight. From that time 
on he felt weak and miserable and complained of thirst. The 
condition has since remained unchanged, and he complains at 
present principally of extreme weakness, of intense thirst, and of 
very weakening diarrhceal attacks. 

Present Condition. — Color of lips and cheeks very pale, ansemic. 
Tongue furred with a whitish coat. Chest organs intact. The 
stomach extends to one finger's width below the navel. A 
splashing sound can be easily produced in the gastric region. 
There is nowhere any tumor. There are no sensitive spots dis- 
coverable in the abdomen. The knee reflex is present. The 
urine contains neither sugar nor albumin. 

Patient was treated for some time, at first with injections into 
the bowel (tannic acid 2.0 to a quart of water once daily), there- 
after with the administration of peptonate of iron. These means, 
however, failed to be of any benefit whatever; the tired feeling 
and weakness persisted, and the frequent attacks of diarrhoea 
likewise remained unchanged. 

November 21st, 1894. — Examination of the stomach one hour 



ACHYLIA GASTRICA. 357 

after Ewald's test breakfast: HC1 = 0; acidity = 2; lactic acid = 0; 
rennet =0; pepsin = 0; biuret reaction = 0; erythrodextrin = 0; 
sugar + . Quantity of liquid very small; the bread particles not 
minute; no admixture of mucus. 

November 23d. — When fasting, stomach empty. Achylia 
gastrica is diagnosticated, and the patient treated with intra- 
gastric faradization. The diet is arranged in such a manner 
that it does not contain very much meat, and is instead rich in 
food taken from the vegetable kingdom. 

After two weeks of this treatment the sensation of weakness 
was no longer felt. Patient began to look better. His cheeks 
had a red color, the bowels were regular, and the troublesome 
sensation of thirst that formerly was so annoying disappeared. 

December 17th. — Examination of the stomach one hour after 
Ewald's test breakfast: HC1 = 0, of neutral reaction; biuret reac- 
(ion— 0; rennet = 0; pepsin = 0; erythrodextrin = 0; sugar + . 
Small quantity of fluid; the bread particles not minute; no 
mucus. 

Patient asserts that he feels well; he can walk great distances 
without feeling tired. 

December 20th. — One and a half hours after the test break- 
stomach empty. 

December 31st. — Patient takes one glassful of milk; one hour 
afterward he takes a glassful of water, and his stomach is directly 
faradized for ten minutes. Then the gastric contents are ob- 
tained by means of a tube; they consist of uncurdled milk 
diluted with water and are of neutral reaction. 

Patient was examined at various times in January and Febru- 
ary. 1895, and there was always found a complete absence of 
ic juice. The absorption of the stomach was examined by 
means of the potassium iodide test, and the iodine could be 
*ed in the saliva after a lapse of eleven minutes. Patient's 
health was and has remained thus far in very good state; his 
ir, bowels regular, and stools well formed; no at- 
tacks of diarrhoea. 

April 15th, 189.5. — Patient has gained ten pounds in weight. 

January, 1896. — Patient is in perfect health and has gained 
forty pounds in weight. 

While the subjective complaints are thus of quite a manifold 



35S DISEASES OF THE STOMACH. 

nature and may often be entirely absent, particularly as regards 
the .stomach, the objective symptoms are always alike and show 
the following peculiarities. One to one and a half hours after 
Ewald's test breakfast: 1. The pieces of roll are not minutely 
minced and unchanged. 2. The reaction is very weakly acid 
or neutral, usually the acidity is 4. 3. Hydrochloric acid is not 
present. 4. Lactic acid is either absent or present in traces 
and can be discovered only after a thorough shaking with 
ether. 5. Neither propeptone nor peptone is present. 6. The 
tests for the pepsin and rennet 1 ferments give negative results. 
7. The stomach contents do not smell bad, and do not otherwise 
give the appearance of decomposition. 8. Absence of mucus. 
9. The quantity of liquid found in the stomach of these patients 
one hour after the test breakfast is remarkably small. Aside 
from the fluids soaked in and around the particles of bread 
there is hardly any liquid at all. The gastric contents thereby 
acquire a peculiar, characteristic appearance, and look different 
from what they do in other affections of the stomach. 

The small amount of fluid in the gastric contents of patients 
w T ith achylia may be explained in the following way: Besides 
the water (or tea) ingested into the stomach with the test 
meal, there is no addition of juice (or liquid) during the stay 
of food in this organ. As the more liquid chyme, as a rule, 
leaves the stomach quicker than the more solid substances, 
these latter alone will then, after a while (about one hour 
after Ewald's test breakfast), be found present. 

The motor function of the stomach is as a rule not impaired 
or slackened; in some of the cases it is rather somewhat 
hastened (Solomon S ). 

The absorption faculty of the stomach is, according to my 
experience, not in any way retarded. 

Course. — This disease runs a very protracted course; cases in 
which the stomach resumes secretion after a cessation of several 

1 The rennet zymogen, however, may still be found present. 



ACHYLIA GASTRIC A. 359 

years are very rare. I have had a number of cases of this kind 
under observation. As a rule, the subjective sj^mptoms can be 
greatly ameliorated or entirely removed by prolonged rational 
treatment, while the objective symptoms of achylia remain 
unchanged. 

Diagnosis. — To arrive at a diagnosis of achylia gastrica 
repeated examinations of the gastric contents are required 
for the detection of the above-mentioned characteristic points. 

The points of differential diagnosis between achylia gastrica 
and cancer of the stomach have been described under the latter 
affection (p. 308) and are therefore omitted. 

Prognosis. — The prognosis of cases of achylia gastrica is good 
quoad vitam, a view which I have represented in several papers 
and which is now generally accepted by most writers. The 
small intestine perfectly replaces the digestive work of the 
stomach, and the organism is not only enabled to maintain 
its equilibrium but also to gain in weight. 

Treatment. — Therapeutic measures will be indicated only in 
cases presenting subjective symptoms. 

The treatment will have to be carried out in the two following 
directions: 1. To stimulate the mechanical action of the 
stomach. 2. To arrange the diet in such a way that the food 
asily accessible for the intestinal digestion. 

The first point is best achieved by stimulating the stomach, 
as by lavage and, principally, direct faradization of the organ. 
In some of the cases I have not employed any medicaments 
whatever, and in others I have administered condurango or nux 
vomica or muriatic acid. 

simulating hyperchlorhydria require special attention 
for their hyperchlorhydric symptoms. The use of water (half 
1 or a glassful) about one or two hours after meals, 
just at the time the distress is experienced, appears to be very 
rational. The water acts as a diluent and diminishes the rub- 
bing of solid particles against the gastric walls. Experience 



360 DISEASES OF THE STOMACH. 

teaches that in many of these cases this simple means brings 
relief. In some instances milk and crackers may be given 
between meals also with benefit. If these measures are not 
sufficient, the bromides will then be found useful, bromide of 
sodium or strontium being administered in twelve-grain doses 
twice daily. 

In reference to diet, it is of utmost importance to see that the 
food is broken into very minute particles or can be easily 
divided by chewing. For, on the one hand, all kinds of meat 
are in no way altered in the stomach and reach the intestine 
in the shape in which they entered the cardiac orifice; on the 
other hand, the starchy substances contained in the vegetable 
food cannot become converted into maltose so long as the 
albuminous membrane occluding them has not been opened. 

In the stomach of these patients starch, as such, when 
accessible to the action of ptyalin, undergoes conversion into 
sugar very rapidly. 

Vegetable food is, as a rule, here very well borne. Strained 
pea and bean soups may be highly recommended on account 
of their richness in albumin. Kumyss or zoolak, or some- 
times bonny-clabber well beaten with a spoon, or plain milk 
with the addition of bread or crackers with butter, are highly 
advantageous. Meats are to be allowed only in small quan- 
tities, best well hashed and broiled, or the white part of chicken. 
Brain, sweetbread, fish, and raw oysters are very suitable. In 
the grave cases it is advantageous to administer meat powder 1 
(two to three tablespoonfuls or even more, pro die, in soup or 
milk). 

The usual beverages, as tea, coffee, cacao with milk and 
sugar, besides small quantities of beer or stout, may be allowed. 



1 Meat powder can be prepared in the following manner. Raw lean 
meat is cut into thin slices and dried on a glass plate on the stove for about 
two or three hours, then pounded in a mortar and ground twice in a coffee- 
mill. 



ACHYLIA GASTRICA. 361 

Outline of Diet in Achylia Gastrica. 

Calories. 

5 a.m.: oatmeal with cream, 150 gm., 395 

cacao with milk, 200 gm., 135 

toasted bread, 60 gm., 135 

butter, 20 gm., 163 

12 m.: pea soup, 200 gm., 190 

scraped meat (broiled) or fish, 100 gm., 213 

baked or mashed potatoes, 50 gm., 63 

spinach or turnips, 50 gm., 82 

wheaten bread, 60 gm., 135 

butter, 20 gm., 163 

6 p.m.: two eggs (soft boiled or scrambled), 160 

farina with milk, 200 gm., 432 

wheaten bread, 60 gm., 135 

butter, 20 gm., 163 

tea, 200 gm. (milk, 30 gm. ; sugar, 10 gm.), 60 

9:30 p.m.: kumyss, 200 gm.; crackers, 30 gm.; butter, 10 gm. ; or, in- 
stead, a sandwich with cream cheese or caviar, or sardines 
and beer, 323 

2,947 

Here also, as in all other chronic disturbances of the digestive 
tract, it will be of importance to pay attention not only to the 
quality but also to the quantity of food taken. And the 
greatest stress must be laid upon the injunction that a sufficient 
quantity of food is taken. It is always preferable to have the 
patient partake of too large a quantity, of food rather than too 
small a quantity, in consequence of which a condition of sub- 
nutrition is so often established. 

When the intestine has adapted itself to the greater amount of 
work and the nutrition is maintained on a well-regulated basis, 
achylia gastrica need not cause any trouble whatever, and the 
patient may enjoy perfect euphoria. 



CHAPTER XI. 

FUNCTIONAL DISEASES WITH VARIABLE 
LESIONS.— Continued. 

Ischochymia. 

Synonyms. — Dilatation of the stomach; ectasia ventriculi; 
gastric insufficiency; stenosis of the pylorus. 

Definition. — An affection characterized by the constant 
presence of food in the stomach, even in the fasting state. 
There is always a retardation or retention of chyme in the 
organ. 

General Remarks. — The term " clinical dilatation of the 
stomach," as is well known, is applied by the majority of 
authors to a condition in which there is stagnation of food in 
the stomach. Taken in its true sense, however, the word 
"dilatation of the stomach," or "ectasia ventriculi," refers 
merely to the dimensions of the organ. This explains the 
frequent misunderstandings caused by these expressions. 
Some speak of dilatation of the stomach as soon as the limits 
of this organ are found enlarged; others, however, only in 
those instances where there are found remnants of food in 
the morning in the fasting condition. Rosenbach, 1 therefore, 
suggested the term "motor insufficiency of the stomach," to 
designate that condition in which the transportation of food 
from the stomach into the small intestine is at fault. In an 
article recently published, Boas 2 expresses the opinion that the 
terms "dilatation of the stomach" and "ectasia ventriculi" 

1 Rosenbach: Volkmann's Sammlung klin. Vortrage, No. 153, 1878 

2 Boas: Deutsche med. Wochenschr., 1894, No. 28, p. 576. 

362 



ISCHOCHYMIA. 363 

should not be used at all, and suggests the term ''gastric insuf- 
ficiency of the first and second degrees" instead. The first 
degree corresponds to the atonic condition, the second to the 
stagnation of food. Although, like Boas, I am fully convinced 
of the importance of differentiating between cases of stagna- 
tion of food and those in which the transportation of the 
chyme is only slightly retarded, I do not, however, believe 
that we ought to discard the expression "dilatation of the 
stomach/' or that the proposed term, "gastric insufficiency of 
the first and second degrees" is well selected. 

"Dilatation of the stomach" is a term applied to the condition 
of the volume of the stomach, and signifies an enlargement of its 
dimensions. Such conditions not only do exist, but are an 
every-day occurrence. There is, therefore, no reason for dis- 
carding the term "dilatation of the stomach." Whether this 
enlargement of the dimensions of the stomach has been due 
to physiological or pathological processes, or whether it creates 
abnormal conditions or not, will have to be investigated in every 
individual case. 

The term "insufficiency" or "mechanical (motor) insufficiency 
of the stomach," signifying a retardation in the transportation 
of the food from the stomach into the intestine, appears to me 
ill chosen; for the word "insufficiency," or "mechanical insuf- 
ficiency of the stomach," does not clearly point out the condi- 
tion caused by the transportation of chyme from the stomach 
into the intestine. Moreover, the term "mechanical insuffici- 
ency of the stomach" means that the fault for the non-trans- 
portation of food lies in the stomach, which is not the case in 
" instances. 

Analogous to the expression "ischuria," which signifies an 

abnormal collection or stagnation of urine in the bladder, 

without giving the cause of this condition, the word "ischochy- 

mia" 1 might be applied in order to designate an undue stagna- 

behochymia, from tovova detain, and yv/*os= chyme. 



364 DISEASES OF THE STOMACH. 

tion of chyme in the stomach. 1 Thus "ischochymia" will embody 
a complex of symptoms without stating the cause. The latter 
will have to be discovered and further determined in each case. 

Symptomatology. — Ischochymia may last either a short period 
of time (a few days to one week) or it may become chronic or 
stationary. 

Acute ischochymia is occasionally found as a result of an acute 
inflammatory process of the gastric mucosa in consequence of 
gross errors in diet and the like. Ischochymia, then, although 
quite rarely, may develop alarming symptoms and may even 
lead to a fatal issue. Several such instances have been reported 
under the heading of acute dilatation of the stomach by 
Hunter, 2 Frankel, 3 and Boas, 4 the case of the latter author 
ending in recovery. Whether acute ischochymia is due to a 
paralysis of the gastric muscles, or whether it is caused by a 
spasmodic contraction of the pylorus, is as yet undecided. 
Probably both conditions exist. In these instances it appears 
that nothing passes from the stomach into the duodenum; any- 
thing which is taken in the way of food or drink collects in the 
stomach and distends it. The presence of gastric juice may 
still further increase the amount of liquid within the organ, 
and in this way aggravate the condition. The prolonged 
stagnation of chyme within the stomach gives rise to manifold 
processes of decomposition and fermentation. Vomiting usu- 
ally occurs and brings temporary relief. The direct cause of an 
eventual fatal issue is quite difficult to state. It may be due to 
auto-intoxication or to some more direct injury to the vagus 
nerve. A similar condition occurs off and on soon after 
operations on the stomach or other abdominal organs. 

Transient ischochymia may appear in conditions in which the 

1 See Max Einhorn: " Diagnosis and Treatment of Stenosis of the Py- 
lorus.'' Medical Record, January 19th, 1895. 

2 Hunter: Medical Record, 1889. 

3 A. Frankel: Deutsche med. Wochenschr., 1894, No. 7. 
* y. Boas: Deutsche med. Wochenschr., 1894, No. 8. 



ISCHOCHYMIA. 



305 



muscles of the stomach are weakened and fail to do their work 
properly, or in a beginning stenosis of the pylorus. In both 
instances the ischochymia is only slightly marked — that is, while 
there is a retention of some food in the stomach, the greater 
part is transferred into the small intestine. In the fasting con- 
dition the amount of chyme present in the stomach is not large. 
In a few days the stomach, as a rule, recuperates and by more 
energetic action succeeds in accomplishing its work properly, 
that is, transports all the chyme to the duodenum during the 
night. 




Fig. 01. — A Specimen of Chyme Obtained from the Stomach in the Fasting Condition 
(from a Patient with Ischochymia [H.]), showing (a) vegetable cells, (b) partly digested 
muscle fibres, (c) starch grains, (<7) fat, (e) yeast cells, bacilli and cocci. 



Hani ischochymia is always a serious trouble. Processes 
of fermentation are almost constantly present (Fig. 91). It is 
here that the occurrence of manifold gases has been described; 

;• instance, sulphuretted hydrogen, hydrogen, marsh gas, 
oxygen, and carbon dioxide. In some of these patients the gas 
eructated burns with a flame if lighted (Ewald). Very often it 
near, when auscultating the gastric region of these 
patients, a constant bubbling or sizzling sound, arising from the 
rapid formation of the gas. If the gastric com cuts of such 



3G6 DISEASES OF THE STOMACH. 

patients be obtained and put in a cylinder, one can perceive 
the bubbles of gas rising to the surface. The amount of gas 
may be determined, according to Kuhn, 1 by placing small 
quantities of the nitrate in a fermentation tube which is kept 
at blood temperature for several hours. 

Chronic ischochymia is almost always accompanied by the 
following train of symptoms : The appetite is frequently poor, 
although at times it may be abnormally increased. The sensa- 
tion of thirst is usually augmented and in some cases con- 
stantly present, and the patient is continually tormented with 
a feeling of extreme dryness in his throat. A feeling of oppres- 
sion almost always exists, which at times may alternate with 
more or less intense pains. The eructation of gas, which has 
a disagreeable odor, is often met with. Vomiting of large 
quantities of chyme, in which particles of food from previous 
days may be recognized, is one of the most important symp- 
toms. The vomiting may occur once or twice a day, or once 
only in two or three days. There are very few cases in which 
the bowels work regularly; as a rule, the most obstinate con- 
stipation is found. Emaciation is present in almost all 
instances, and it may occasionally reach such a degree that the 
patient literally looks like a skeleton. 

In the advanced stages of ischochymia, the quantity of urine 
voided in twenty-four hours is greatly reduced, and may 
sometimes be less than 600 c.c. 

Etiology. — Ischochymia is due to a diminished muscular 
work of the stomach, or to stenosis of the pylorus, or to an 
open ulcer within or very near the pylorus. In the latter 
instances a spasmodic contraction of the pylorus takes place. 

Course. — The course of ischochymia will materially differ, 
according to the etiological factors causing this condition. 
Ischochymia due to muscular weakness of the organ (atony) 
may occasionally disappear without medical aid and is in most 

1 Kuhn: Deutsche med. Wochenschr., 1892, Nos. 49 und 50. 



ISCHOCHYMIA. 367 

instances amenable to rational treatment. Ischochymia due 
to stenosis of the pylorus will run a different course, according 
to the nature of the stenosis. If the latter be of a benign 
type (hypertrophy of the pylorus or stricture of the pylorus due 
to cicatricial contraction) there are at first ameliorations which 
are due to an hypertrophy of the muscles of the stomach and 
to increased compensatory action, also to a subsidence of a 
hyperaemic or cedematous swelling of the narrowed pylorus, 
whereby the canal is again patent. 1 Frequently, however, the 
symptoms of stenosis return as soon as the pylorus has become 
still narrower, until at last sufficient compensation cannot be 
effected. In this stage the only means of saving the life of the 
patient is surgical intervention in the way of establishing a 
larger opening between the stomach and the small intestine, 
winch may be done either by Heinecke-Mikulicz's pyloroplasty 
or by a gastroenterostomy. 

In all these cases a radical cure can thus be accomplished. 
The patients then gain considerably in weight, have no pain, 
no digestive troubles whatever, and can attend to their daily 
vocations in life. They all feel as if " new-born," if I may be 
permitted to use this expression. In two of these patients I 
convinced myself, by means of several experiments, of the 
prompt forwarding of the contents of the stomach into the 
intestines. The chemical condition was not markedly changed; 
the gastric volume in the two patients was not appreciably 

Led six months after the operation. In one of my newly 
observed cases, 2 however, there was a marked diminution in 

;ze of the stomach two months after the gastroenteros- 
tomy. If the stenosis is of a malignant type, then the course 
will correspond to the original disease. However, it is here also 



1 Max Einhorn: "Further Remarks on Ischochymia and Its Treatment.'' 
American .Medicine, June 3d, 1905. 

\ Einhorn: "A Further Contribution to Our Knowledge of Ischo- 
chymia. " Medical Record, June 19th, 1897. 



308 DISEASES OF THE STOMACH. 

possible to relieve the symptoms of ischochymia by an early 
gastroenterostomy. 

Before taking up the diagnosis, we may consider some symp- 
toms which are characteristic of the just-mentioned etiological 
factors: 

Ischochymia due to Atony.— In this condition the residue of 
chyme found in the stomach in the fasting state consists of 
some liquid and fine particles of food. Even if coarse particles 
of food (as, for instance, asparagus, spinach, rice grains not too 
well cooked, chestnuts, and the like) have been ingested on the 
previous day, the residue of these substances is not so very 
much pronounced, while in ischochymia due to stenosis of the 
pylorus it will be found that the entire quantity of such coarse 
particles of food, which undergo no changes in the stomach, 
will remain within the organ. In atony of the stomach the 
difficulty merely lies in a deficient peristalsis of the stomach, 
i.e., the contents are not sufficiently pushed toward the pylorus. 
But whatever reaches this outlet can pass without much incon- 
venience, whether it be very fine or whether coarser particles 
be present. This is quite different in stenosis of the pylorus, 
for here the main obstacle is the narrowness of the canal, which 
does not permit of the passage of coarser particles of food. 
The peristalsis of the stomach, even if the muscles work with 
increased activity, is here without much avail. 

As cases of ischochymia due to a weakened condition of the 
muscular action of the stomach are quite rare, the following 
case, which I have observed very recently, will not be without 
interest : 

Patient H , aged 46 years, had been suffering for the last 

three years with an intense burning sensation, beginning at the 
pit of the stomach and extending all the way up through the 
oesophagus to the pharynx. There was a feeling of pressure in 
the gastric region, which occasionally alternated with pains. 
Besides, the patient complained of belching of bad-smelling gases, 



ISCHOCHYMIA. 369 

which were very disagreeable, especially to his wife and imme- 
diate family. His appetite was fair, and constipation existed 
only in a slight degree. His weight had steadily decreased dur- 
ing the last three years, so that he had lost over fifty pounds 
within that period. The examination of the patient revealed 
that the stomach was quite enlarged; a splashing sound extended 
to about two finger's width below the navel, and a succussion 
sound could be easily produced. The examination of the stom- 
ach in the fasting condition revealed the presence of a consider- 
able quantity of chyme, which presented all the signs of marked 
decomposition (almost fetid odor, presence of sulphuretted 
hydrogen; microscopically, each specimen was full of micro- 
organisms, yeast cells, and sarciruc) ; free hydrochloric acid, 
however, was present in quite normal amounts. After a thor- 
ough cleansing of the organ, the patient was told to partake 
of light (more liquid) food during the day, and for supper of 
some meat, a liberal amount of rice, not too well cooked, and 
some bread. 

On the following morning the patient was again examined in 
the fasting condition. ^Vhile some chyme was present in the 
stomach, the amount of rice found was very small indeed, so 
that it was rather difficult to recognize its presence with cer- 
tainty. The result of this observation, combined with the points 
derived from the history of the disease (the symptoms steadily 
keeping on and slowly gaining in severity, no decided free inter- 
missions of long duration), seemed to point to an atonic state of 
the gastric muscles, rather than to stenosis of the pylorus. The 
beneficial results of the treatment, which was based on this view 
(regulation of diet, four or five meals daily, interdiction of larger 
amounts of liquids, large doses of bismuth, with the addition of 
small doses of resorcin, and occasional lavage of the stomach), 
justified the conclusion that the diagnosis was correct. The 
patient after a few weeks felt much better, lost his burning 
sensation, while the stomach in the fasting condition was now 
found empty, and only after the ingestion of a very large supper 
stomach on the following morning contained a small quan- 
if chyme, but not smelling badly. After three months the 
patient had gained twelve pounds in weight, and is steadily im- 
proving. 

24 



370 DISEASES OF THE STOMACH. 

Benign Stenosis of the Pylorus. — Only rarely can the pylo- 
rus be palpated as a small oval tumor (of small hen's egg 
size); in most instances the pylorus cannot be felt. All cases 
reveal a long period of sickness (extending from two to fifteen 
years), in which the appearance of pain plays the greatest part. 
Although at first, either with or without therapeutic aid, there 
appear ameliorations, these periods of euphoria, however, are 
again and again interrupted by fresh attacks of sickness. 
They constantly become more violent and of longer duration, 
and the pains subside only after an artificially induced or spon- 
taneous vomiting spell. Still later, when the ischochymia de- 
velops to a higher degree, not even vomiting brings entire re- 
lief, and the patients are subjected to the greatest pain and 
suffering. They emaciate quickly, and, if there is no radical 
intervention at this period, death from starvation inevitably 
eventuates. 

The following two cases present good instances of a benign 
stenosis of the pylorus : 



Case I. — Louis L , 40 years of age, lawyer, began to be 

troubled with his stomach in the summer of 1891. The patient 
was attacked with pains after meals during a period of ten days, 
when this symptom disappeared suddenly. There was no 
vomiting. For six months the patient felt well, not having any 
pains whatever; he noticed, however, that he became tired quicker 
than heretofore. In the winter of 1892 (February) he again 
had an attack of pain, lasting more than a month. During this 
attack he vomited twice. He felt well until July, when he had a 
fresh attack of pain extending over two to three weeks, with 
four vomiting spells. On account of the severe pains he could 
not lie quietly, but had to walk frequently to and fro in his room. 
In December, 1892, the patient had another attack, lasting until 
February, 1893. He then had to vomit frequently (nearly every 
other day) . He had never vomited any blood. Since the begin- 
ning of the sickness his bowels were constipated. 

On January 27th, 1893, Dr. Charles Simmons called me in for 



ISCHOCHYMIA. 



371 



a consultation and kindly entrusted me with the treatment of the 
patient. 

When I first saw the patient he presented the picture of a very- 
sick man in agonies of pain. He looked pale and emaciated; he 
asserted that he had lost about forty pounds in weight since the 




_'. — Cross-section of a Benign Hypertrophied Pylorus. (From the writer's own 
observation.) X60. 



beginning of his ailment, and complained of a feeling of constric- 
tion in the abdomen and of shortness in breathing; he further 
plained of vomiting large quantities of fluid, and of obstinate 
constipation. During the last fourteen days the patienl had 



372 DISEASES OF THE STOMACH. 

taken largo doses of opium; he was, however, very rarely entirely 
free from pain. 

The examination of the chest organs did not reveal anything 
abnormal. Tongue slightly coated; pulse, 90; temperature, 98° 
F. The whole abdomen was more or less bloated and quite 
tense. In the gastric region no splashing sound could be pro- 
duced. No tumor could be felt. The fluid which the patient 
vomited a few hours before showed many blackish flakes floating 
in it, contained a great quantity of free HC1, gave no reaction for 
lactic acid, and had an acidity = 90. 

Patient was instructed to have a light meal (well-scraped meat, 
oysters, milk, crackers) every two hours. The quantity of 
liquids was reduced, and he was allowed to take only 150 c.c. at 
a time. Besides, oil clysmata were administered. Under this 
treatment the patient felt somewhat better, although his ailment, 
on the whole, did not change. On January 29th he was instructed 
not to take any food after his eight o'clock evening meal until 
the next morning. On January 30th, at 8 a.m., when fasting, the 
tube was inserted into the stomach and two quarts of liquid 
withdrawn. The stomach was then washed with lukewarm 
water. Patient felt exceedingly well after this lavage. 

The withdrawn gastric liquid was analyzed; in this sample 
there were the blackish flakes mentioned above. The examina- 
tion showed: HC1 + ; acidity = 88; lactic acid not present; pep- 
tone +; propeptone + ; rennet and pepsin-}-; erythrodextrin + . 

Microscopically, no particles of meat can be found; amy- 
laceous grains, yeast cells, and bacteria are present in considerable 
quantity. Teichmann's test for blood shows the absence of 
hsemin. 

Thus the withdrawn liquid consisted principally of gastric 
juice and of remnants of food taken the previous day. 

February 1st, 1893, at 10 p.m., the stomach of the patient was 
thoroughly washed out. During the night he did not partake of 
anything, and on February 2d, at 8 a.m., the stomach was exam- 
ined with the tube, and a small quantity of liquid withdrawn 
(150 c.c). The examination of this gastric liquid showed: 
HC1 + ; both ferments present; acidity = 70. 

The patient was treated with lavage for another week. He 
felt better and could walk outdoors. The pains, however, per- 
sisted, although they were less severe, and the stomach was 



ISCHOCHYMIA. 373 

never empty in the morning, but contained more or less liquid 
with food remnants. 

February 11th, 13th, and loth. — Intragastric galvanization 
was applied without, however, materially improving the patient's 
condition. The diagnosis of benign stenosis of the pylorus was 
made and an operation strongly recommended. 

Dr. F. Lange undertook the operation on February 22d. The 
pylorus was found greatly constricted. Heinecke-Mikulicz's 
pyloroplasty was performed, and after a month's confinement 
the patient left the clinic. Although he was now able to partake 
of a more varied and coarse diet without vomiting, he nevertheless 
constantly complained of pains and had to resort to opium. 

On March 30th the stomach was examined one hour after the 
test breakfast: HC1 + ; no lactic acid; acidity =120, no remnants 
of food from the previous day. It was supposed that this high 
degree of acidity might be the cause of the pains. The patient 
was therefore instructed to take half a teaspoonful of bicarbonate 
of soda three times a day, two hours after meals. This worked 
like a charm; the pains entirely disappeared and he began to 
gain rapidly in flesh. After six months' medication with the 
soda the patient discontinued its use and felt perfectly well with- 
out it. He now attends to his business and has gained seventy 
pounds since the operation. 

Case: II. — Mrs. P. L , 43 years of age, mother of three 

children. Her mother died of cancer. Patient has been, suffer- 
ing for six years. The ailment began with diarrhceal trouble 
lasting for two years. (Patient is unable to state whether the 
stools were of dark color.) Since four years cramps in the 
stomach. The pains are extremely severe; there is relief after 
belching or flatus. Never had any jaundice. For the last two 
years intense burning in the stomach with frequent vomiting. 
Never vomited any blood. During the night the pains are ex- 
tremely severe and disturb sleep. Patient during last months 
'•onsiderably in weight (about thirty pounds). She was 
referred to me by Dr. Willy Meyer for examination and diagnosis. 

Present Condition. — Chest organs intact. Palpation of the 
abdomen reveals a small cylindrical tumor, of the size of an egg, 
situated to the right of the navel. This tumor is easily movable 
in all directions and has a smooth surface. A Bplashing sound 
can be produced in the gastric region from one, to two fingers' 



374 DISEASES OF THE STOMACH. 

width below the navel. The gastric region is not painful to 
pressure. The liver is not enlarged. 

After lavage the patient is examined with the gastrodiaphane; 
the stomach is found considerably enlarged and occupying a low 
position. 

On the following day the patient is examined with the tube 
one hour after a cup of tea without bread (the patient being in 
the fasting condition with the exception of the tea). The 
stomach contained about 300 c.c. of a slightly greenish liquid 
(presence of bile), in which were only a few remnants of food 
(several bread particles) from the previous day. The analysis 
showed: HC1 + ; acidity = 42; free HC1 = 24; lactic acid = 0. 

The patient was then treated for a week with lavage and 
chloral hydrate at the New York Post-Graduate Hospital; there 
was, however, no material improvement in her condition. 

On a subsequent examination one and one-half hours after 
Ewald's test breakfast: HC1 + ; acidity = 50; no lactic acid; the 
obtained gastric contents amounted from 300 to 400 c.c. and 
contained food from previous days; for instance, rice, which had 
been taken on the previous night, and several grape-skins, which 
had been taken three days before. This time no bile could be 
detected. 

The diagnosis (of benign stenosis of the pylorus) was made and 
the patient operated on by Dr. Willy Meyer. 1 After opening the 
abdomen the tumor, which proved to be the thickened pylorus, 
was resected. The duodenum was then inserted into the stom- 
ach by means of Murphy's button. The patient passed an un- 
disturbed convalescence, evacuated the button in her stools 
during the third week, and has since been well. She has gained 
twenty pounds and has had no pains whatever. 

The resected, highly thickened, and stiff pylorus could not be 
macroscopically distinguished from a cancerous organ; the micro- 
scopical examination, however, showed that it was merely an 
hypertrophied pylorus. 2 



1 Heinecke-Mikulicz's operation could not be done in this case: (1) 
on account of suspicion of cancer; (2) because the lumen was too narrow and 
the thickening of the walls of the pylorus too considerable. 

2 The wall of the pylorus, after specimen was preserved in alcohol for 
about nine months, measured in thickness 1^ cm. 



ISCHOCHYMIA. 375 

Malignant Stenosis of the Pylorus or Cancerous. Stenosis. — 
Stenosis of the pylorus due to carcinoma is of frequent occur- 
rence, "and is developed sooner or later in the course of most 
cancers of the stomach appertaining to this region. Cases in 
which the diagnosis is made at an early period are most suit- 
able for surgical interference. When possible, the tumor should 
be resected; otherwise gastroenterostomy should be per- 
formed. An operation appears to me to be always indicated 
when there exists ischochymia for some time, and either a 
tumor is felt or else the diagnosis of cancer of the pylorus can 
be made by other deductions — unless the tumor has assumed 
too extensive dimensions or the patient be too weak to stand 
an operation. Assuredly one can in many cases give great 
benefit for a more or less prolonged period of time, and the 
sooner the greater. Of the considerable number of cases of 
cancerous stenosis of the pylorus which I have seen a great 
many have been operated upon. In some resection of the 
pylorus was practised; in all others gastro-enterostomy was 
performed by well-known surgeons of this city. The mortality 
amounted to 10-15 per cent. Those recovering from the op- 
eration lived from three months up to two or three years. 

All cases of cancerous stenosis reveal a more or less short 
period of illness 1 (five months to one and a half years at the 
utmost) and show considerable ischochymia. In most in- 
stances, with but few exceptions, a gastric tumor can be pal- 
pated. In some of the cases the position of the tumor can 
be accurately determined with the gastrodiaphane. By means 
of transillumination, it can be ascertained whether the tumor 
occupies the greater or lesser curvature of the stomach. I ap- 
pend the drawings of two cases as viewed with the aid of the 
odiaphane (Figs. 93 and 94). Both patients had been 
operated on by Dr. F. Kammerer, at the German Hospital, 

1 There are, however, exceptions to tin's rule. Thus a cancer which has 
on the basis of an ulcer may give a long period of di» 



376 



DISEASES OF THE STOMACH. 



and the diagnosis as to position of the tumor was found to be 
correct. Most cases show the absence of free HC1 and the 
presence of lactic acid, although in some instances free HC1 
is present in considerable quantities and lactic acid absent, as 
the following case demonstrates: 

March 9th, 1894.— Oscar F— 



•, 32 years of age, silk manu- 
facturer, always robust and healthy, has been suffering for the 
past six or seven months from digestive troubles which have been 




Fig. 93. — Result of Gastrodiaphany in Patient K. N , with Tumor in the Gastric 

Region, a, The transilluminated zone; b, the dotted spot slightly translucent on pressure; 
c, the black-colored spot remains dark even on pressure. 



constantly increasing. They consist principally of pain, and 
for the last four months also of frequent spells of vomiting. Pa- 
tient has lost forty pounds in weight. Bowels not materially 
impaired. Poor appetite. Patient has never vomited any 
blood. 

Present Condition. — Patient looks thin and cachectic. Lips 
and cheeks are extremely pale. Chest organs intact. Palpa- 



ISCHOCHYMIA. 



377 



tion of the abdomen shows painfulness on pressure in the gastric 
region and an egg-sized tumor somewhat to the right and above 
the navel. This tumor is not especially painful on pressure, 
presents a smooth surface, and is easily movable. A splashing 
sound can be produced in the gastric region extending to two 
fingers' width above the symphysis. 

March 9th, at 6 p.m. — Patient had taken a glassful of milk 
at 10 a.m. and had had nothing since; it was therefore eight hours 




Fig. 94. — Result of Gastrodiaphany in Patient M. R , with Tumor in the Gastric 

Region, a, The transilluminated zone; b, the dotted spot slightly translucent on pressure; c, 
the black-colored spot remains dark even on pressure. 



after his last meal. Examination by means of the tube revealed 
the presence of two pints of chyme. The latter showed a brown- 
ish color, contained small particles of casein, and various other 
food-stuffs. HC1 + ; no lactic acid; acidity = 1 18; freeHCl = 94. 

Patient is instructed to take with his supper rice, milk, and 
crackers. 

March 10th. — When fasting, two pints of chyme are with- 
drawn from the stomach. The chyme presents a brownish 
color and contains food from previous days — rice, particles of 



378 DISEASES OF THE STOMACH. 

bread, and casein. Microscopically: yeast cells, granules of 
starch, sarcinae, bacteria, brown pigment. Chemically: HC1 + ; 
no lactic acid; acidity = 112; peptone + ; propeptone + ; rennet + ; 
erythrodextrin + little; achroodextrin +much. 

March 12th. — The stomach is examined in the fasting condi- 
tion and the same results are obtained as on the 10th. 

The high degree of ischochymia and the presence of a tumor in 
the pyloric region pointed with certainty to a stenosis of the 
pylorus. It was questionable, however, whether the process was 
a benign or a malignant one. Whereas the chemical condition of 
the gastric contents pointed toward a benign stenosis, the large 
size of the tumor and the relatively short period of sickness (six 
to seven months) answered more to the history of a malignant 
growth. 

After a consultation with Dr. F. Lange, we both were of the 
opinion that we had to deal here with a cancerous stenosis of the 
pylorus. The high degree of ischochymia appeared to necessi- 
tate surgical interference, which should consist in either resec- 
tion of the pylorus or in gastro-enterostomy. 

Patient was operated on by Dr. Lange, on March 16th, 1894; 
the tumor was found (macroscopically) to be a cancer, and could 
not be resected on account of the numerous adhesions, principally 
with the colon. Gastro-enterostomy was established, and in 
about a month's time the patient was able to leave the clinic and 
partake of a great variety of food. Soon, however, regurgitation 
of bile into the stomach appeared, and a short while afterward 
"peristaltic restlessness" of this organ also developed. Both 
conditions made the patient feel very uneasy. 

April 19th. — Patient was examined one hour after Ewald's 
test breakfast. There was a considerable amount of bile in the 
gastric contents, which did not contain any food from the pre- 
vious day. Chemically: HC1 = 0; no lactic acid; acidity = 22. 

Diagnosis. — In cases of ischochymia due to stenosis of the 
pylorus, benign as well as malignant, symptoms of vomiting 1 

1 Vomiting may sometimes be absent, notwithstanding that ischochymia 
has already developed. I at present have under observation a patient with 
carcinoma pylori (with clearly palpable tumor), who has been ailing for the 



ISCHOCHYMIA. 379 

and pain 1 are almost always present, in connection with a more 
or less considerable loss of weight. Tins condition, however, 
is best recognized by the examination of the stomach by means 
of the tube when fasting. I usually instruct the patient to 
have at Ms supper, on the night preceding the examination, 
beside soup, meat, and bread, some rice, as this latter is very 
easily recognized and as a rule is retained in the stomach when 
the pylorus is stenosed. For tins examination the expression 
method alone is not always sufficient. Whenever no chyme 
is withdrawn by tins method, it is necessary to wash out the 
stomach. In these cases food is then continually found in the 
stomach. The duodenal bucket fails to pass the pylorus. 
Dilatation of the stomach is almost always present; the organ 
occasionally extends from the margin of the ribs far down to 
the symphysis. 

DIFFERENTIAL DIAGNOSTIC POINTS. 
Benign stenosis of pylorus. Malignant stenosis of pylorus. 



Duration of illness Long duration of illness (two to Short duration of illness (five 
fifteen years). months to one and one-half 

years). 
Course of the disease Long intervals without pain, or No periods of perfect euphoria, 
periods of perfect euphoria. but constant and gradual aggra- 

vation of the symptoms. 
Tumor As a rule absent Present in most cases. 



s months. The patient has never vomited nor has he had much pain. 

mplaints merely refer to loss of appetite and obstinate constipation. 

lamination of the stomach in the fasting condition always reveals the 

tee of chyme (coarse food-stuffs are principally found). Although the 

patient, living on a more regulated diet, has gained six pounds within the 

tenth, nevertheless the ischochymia remained unchanged. 

1 The pain occasionally simulates gallstone disease. The latter condition. 

er, can be excluded; for, here, ischochymia is absent. Bee Max 

Einhorn: "Cases of Ischochymia Simulating Gallstone Disease." American 

Journal of Surgery, June, 1908.) 



380 



DISEASES OF THE STOMACH. 
CONDITION OF GASTRIC CONTENTS. 



Benign stenosis of pylorus. Malignant stenosis of pylorus. 



Free HC1. . 

Lactic acid 

Acidity .... 
Rennet . . . 
Odor 



Present in the great majority of Nearly always absent. 

cases. 
Absent in the great majority of As a rule, present. 

cases. 

Always increased Fluctuates between 30 and 90. 

Always present 

Unpleasant, disagreeable. 



Varies. 

Very frequently fetid. 



In the following I shall describe several symptoms which, 
when present, are very valuable, but whose absence does not 
militate against the existence of pyloric stenosis. These symp- 
toms are: 

1. The dilated or abnormally large stomach. 

2. The thickened and readily palpable pylorus. 

3. The peristaltic restlessness of the stomach. 

4. The fermentation products. 

1. The abnormal size of the stomach is pathognomonic only 
if the organ occupies nearly the entire lower section of the ab- 
domen, and contains over three or four litres of fluid. Such 
stomachs are frequently met with in old cases of stenosis of 
the pylorus, and their presence at once awakens the suspicion 
of a narrowing of the pylorus; before this diagnosis can be 
made, however, the presence of ischochymia must be deter- 
mined. In this country considerable weight has been placed 
upon this symptom; yet the absence of this diagnostic sign 
should not lead us astray, for it is our aim to make the diag- 
nosis of pyloric stenosis as early as possible, while the pro- 
nounced, at once perceptible dilatation of the stomach develops 
only in the course of time. 

2. If it is possible by means of palpation to map out the 
pylorus as a smooth, oval tumor, and if ischochymia is present 
and the disease has lasted over one and a half or two years, 



ISCHOCHYMIA. 381 

we can with certainty make a diagnosis of benign pyloric 
stenosis. 

3. Peristaltic restlessness of the stomach is frequently found 
in cases of benign as well as of malignant stenosis of the py- 
lorus. Inasmuch as the peristaltic restlessness of the stomach 
but very rarely occurs as a pure neurosis, this symptom is of 
great significance for the recognition of stricture of the pylorus, 
the more so as an examination for this purpose (simple in- 
spection of the abdomen in the recumbent position) is not 
attended with any difficulty. 

The presence of this symptom in connection with the exist- 
ence of ischochymia speaks in favor of narrowing of the py- 
lorus, and against simple relaxation of the gastric muscular 
coat; the absence of this symptom is of no consequence. 

4. Fermentation products (formation of lactic acid or gases 
in the stomach) are observed almost constantly in all cases of 
ischochymia. Commonly, one or the other kind of fermenta- 
tion is present, that is, either formation of lactic acid or for- 
mation of gases. The lactic acid is found in the stomach in 
cases in which the secretion of hydrochloric acid is consider- 
ably diminished, while the development of gas is encountered 
in cases in which there is an abundant secretion of gastric 
juice. These points, which have been especially emphasized 
by H. Strauss, 1 I can completely confirm on the ground of my 
own experience. 

These fermentation products may be absent, however, not- 
withstanding the presence of pyloric stenosis, if the stomach 
has been treated in a rational manner, that is, has been washed 
out -everal times. 

The constant or frequent occurrence of small quantities of 
bile in the stomach does not in my experience militate against 
the existence of a narrowing of the pylorus; on the other hand, 

1 II. Strauss: Zeitschr. f. klin. Medicin, 1895. 



382 DISEASES OF THE STOMACH. 

it appears to me to point to a firm rigidity of this orifice, in 
consequence of which the latter is never completely closed. 1 

Among the more recent auxiliary measures which are avail- 
able in arriving at a diagnosis, the gastroscope has been re- 
cently employed by Rosenheim and Kelling. In my opinion 
there is no doubt that this instrument has a great future, al- 
though at present it has not been generally utilized. 

A protracted atony of the stomach may at times produce 
ischochymia; it is then, however, not constantly found and 
disappears soon after the regulation of diet and rational treat- 
ment. The same may be said of grave forms of chronic gas- 
tric catarrh. Here also ischochymia is liable to develop under 
favorable conditions. The symptom, however, disappears 
after a few washings of the stomach. The duodenal bucket 
will, likewise, be found to pass the pylorus. In this way I 
believe that these two conditions (atony of the stomach and 
chronic gastric catarrh) can be distinguished without difficulty 
from stenosis of the pylorus, and can give no cause whatever 
for mistakes. 

Treatment. — There are two ways of treating ischochymia: 
(1) Dietetic and medicinal measures (rectal alimentation, fluid 
diet, lavage of the stomach, bismuth, etc.); (2) operative pro- 
cedures (gastro-enterostomy, pyloroplasty, Finney's gastro- 
duodenostomy). 

These two methods of treatment do not antagonize, but sup- 
plement, each other. The indications for both are fairly well 
determined; where one ceases, the other begins. 

Since in by far the larger number of cases of ischochymia a 
stenosis of the pylorus is present, the ideal method of treat- 
ment would consist in forming a new passage for the exit of 



1 Max Einhorn : " A Further Contribution to Our Knowledge of Ischochy- 
mia," I. c. See also, Max Einhorn: "Report of a Case of Narrowing and 
Constant Patency of the Pylorus." The Post-Graduate. Twenty-fifth 
Anniversary volume, 1908. 



ISCHOCHYMIA. 383 

the chyme from the stomach. Yet surgical intervention ought 
not to be recommended immediately in every case, as a cer- 
tain element of risk is still attached to this procedure. The 
mortality of gastroenterostomy and pyloroplasty is rather 
high. It varies among different surgeons and in different 
countries between 5 per cent, and 20 per cent. If we assume 
10 per cent, as the average (among my own patients the mor- 
tality was much higher), we see that we have a mortality per- 
centage that ought to be taken into consideration in advising 
an operation. 

The indications for medical and surgical treatment of ischo- 
chymia may be placed as follows: 

1. Benign ischochymia requires first medical treatment; if 
tins be unsuccessful, i.e., if after a longer period of treatment 
the fasting stomach, on a fluid diet, is not empty, but contains 
food remnants, an operation is advisable. 

2. Surgical intervention is also indicated in benign ischo- 
chymia which has developed subsequent to a condition of 
continuous hypersecretion of gastric juice (preceded by 
hemorrhage or not). 

3. Malignant ischochymia or one of dubious nature in which, 
however, a thickening of the pylorus is found, should also be 
treated surgically (gastroenterostomy, and, if possible, resec- 
tion of the pylorus). 

Benign ischochymia should first be treated by dietetic and 
medicinal measures, because many patients with apparently 
grave cases of this kind frequently get well in this way; and 
second, because an operation is a procedure connected with a 
considerable amount of danger, and should be suggested only 
when absolutely necessary. 

Those cases of ischochymia with preceding gastro-succor- 
rhoea form an exception, and require operation sooner, because 
they are generally complicated with active ulcerated processes 



384 DISEASES OF THE STOMACH. 

in the pyloric region, and because they are frequently accom- 
panied by severe complications (perforations and severe hemor- 
rhages). The danger from operation in this variety of ischo- 
chymia is less than that from possible complications, therefore 
an operation is indicated. 

As regards the third class of cases, referring to malignant 
ischochymia, operative procedures must be recommended, first, 
because these cases grow progressively worse, and, second, be- 
cause a possibility of a radical cure (either by extirpation of 
the tumor or in consequence of the disappearance of the same 
after gastro-enterostomy), even if remote, is given. 

The palliative treatment in the milder cases consists in the 
employment of a fluid or semifluid diet (milk soups, with finely 
ground farina, meat broths with egg, egg and milk), lavage 
of the stomach in fasting condition, followed by spraying with 
a one-per-mille solution of nitrate of silver, and in the admin- 
istration of medicaments which prevent fermentation. Among 
these may be used benzonaphthol, salol, bismuth, and resorcin. 
I frequently give : 

T^ Resorcin, •. 4.0 

Bismuth, subnit., 20.0 

Aq. dest., 200.0 

S. One tablespoonful in a wineglassful of water three times daily, 
half an hour before meals. 

Olive oil, three to four ounces t. i. d. half an hour before 
meals, has been recently recommended by Cohnheim. 1 

In severe cases (frequent vomiting, violent pains, intense 
burning sensations) it is advisable to keep the patients in bed 
for about three weeks, and to nourish them for five days ex- 
clusively per rectum (besides the nourishing enema rectal in- 
jections of water, as recommended by Unverricht, are of great 
benefit when thirst is present and the amount of urine de- 

1 Cohnheim: Arch. f. Verdauungskrankh., 1899, p. 405. 



ISCHOCHYMIA. 385 

creased) and then slowly and gradually adopt a milk diet, as 
in ulcer of the stomach — in this condition, however, much 
more cautiously and slowly. 

Thus, for example, on the sixth day I give only two table- 
spoonfuls of milk every horn, on the seventh day three table- 
spoonfuls, on the eighth day four tablespoonfuls, etc., until I 
have reached 100 c.c. every hour; then I give 200 c.c. every 
two horns, and increase to 300 c.c. On every other morning 
I determine by washing out the stomach in the fasting con- 
dition whether it is empty. 

In this manner it is frequently possible to adapt the stomach, 
first, to a light and later to a heavier diet. The patients then 
increase gradually in weight and appear completely well. Yet 
they cannot be regarded as entirely healthy, because we must 
be constantly prepared for a recurrence of the old affection. 

Moreover, in cases in which it is not possible to remove the 
ischochyinia by palliative measures, the patient may some- 
times maintain a comfortable existence under use of regular 
washings of the stomach and the maintenance of a light and 
rather fluid diet. Such patients, however, are menaced by 
many dangers and can enjoy but few of the luxuries of life, 
and for this reason the clinician should insist that an opera- 
tion is to be regarded as the only correct procedure. 

In benign stenosis of the pylorus the application of massage 
(ten minutes twice daily) to the gastric region can be warmly 
recommended. Likewise the administration of alkalies in ex- 
isting hyperacidity, and the application of the galvanic cur- 
rent when there are severe pains may be profitably tried. For 
the last two years I have attempted, with some success, to 
treat cases of pylorospasm and beginning benign stenosis of 
the pylorus by stretching the latter. 

Two kinds of instruments may be used for the si retching of 
the pylorus, one being a dilating, inflatable catheter for the 



25 



386 DISEASES OF THE STOMACH. 

pylorus, which I 1 described two years ago. This instrument is 
introduced over the thread of duodenal bucket, which must 
be given the night previous. Recently I 2 have used a simpler 
instrument constructed on the principle of the duodenal pump, 
which may be introduced directly (see Fig. 95). 

The new pyloric dilator (see Fig. 96) consists of a small metal 
endpiece to which is attached a thin rubber tube (8 mm. cir- 
cumference and 1 m. long), bearing markings 1 = 40 cm.; 11 = 
56 cm.; 111 = 70 cm. and IV = 80 cm. Right next to the metal 
piece and fastened to it and the tube is a tiny rubber balloon 
covered with silk gauze. The tube is provided with a few 
holes within the balloon and is connected at its distal end with 
a stopcock and a graduated glass syringe. The latter serves 
the purpose of injecting a certain amount of air into the bal- 
loon and thus inflating it. 

In the first two cases of stretching of pylorus I used the 
dilating inflatable pyloric catheter and one of them was fully 
described in the Illinois Medical Journal. 3 All my other pa- 
tients, excepting infants, were treated with the new pyloric 
dilator. 

In cases in which it is difficult to decide whether the instru- 
ment has passed the pylorus, a combination instrument, "py- 
loric dilator and diaphane" (see Fig. 95) or "pyloric dilator and 
aspirator," may be used. The lamp or the aspirating appa- 
ratus help to determine the position of the instrument without 
the necessity of an X-ray examination. 

Method. — The pyloric dilator is introduced in the same man- 
ner as the duodenal pump. After emptying the rubber bal- 
loon of its air contents (this is done by drawing the piston of 
the syringe outward), the cock is closed. The endpiece of the 

1 Max Einhorn : " A New Method of Catheterizing the Pylorus and Duo- 
denum." Medical Record, Oct. 9th, 1909. 

2 Max Einhorn: "On Pylorospasm." Medical Record, Jan. 21st, 1911. 

3 Max Einhorn : " Dilatation of the Stomach and Chronic Benign Ischo- 
chymia." Illinois Medical Journal, June, 1910. 



ISCHOCHYMIA. 387 

dilator is now dipped in lukewarm water and introduced in 
the pharynx of the patient. The latter drinks some water and 
the instrument moves into the stomach. It is now left in the 




Fig. 95. — The Pyloric Dilator and Diaphane. 

digestive tract for several hours, or, best, inserted before the 
patient retires, and left there over night. For in pylorospasm 
it sometimes takes a long time for the apparatus to pass into 



:;ss 



DISEASES OF THE STOMACH. 



the duodenum. In the morning the stretching is performed. 
Before doing this it is necessary to ascertain whether the dilator 
is in the duodenum. This is done by estimating the length 



l\2 XQ 




Fig. 96. — The Pylorodilator: A. Balloon with silk gauze covering in collapsed condition. 
B. The same inflated with air. C. Stopcock. D. Small rubber band to prevent bulging 
out of the gauze bag. 



of tubing within the digestive tract (it should be in to mark 
III or 70 cm.), and by drawing the tube slightly outward. If 



ISCHOCHYMIA. 389 

a slight resistance is felt the probability is that the appa- 
ratus is within the duodenum. In the stomach the apparatus 
may be moved without resistance. If no resistance is encoun- 
tered the balloon is inflated and the pulling now again tried. 
Lack of resistance is then a positive sign that the instrument 
is in the stomach. In this case the balloon must be deflated 
and left in the digestive tract still longer. If after inflation 
of the balloon a distinct resistance is felt, then the instrument 
is pulled slowly forward until the pylorus is reached. Here 
a strong resistance is encountered and the marking on the tube 
generally shows mark II within the mouth. If the tube is now 
drawn forward there is a sensation as if the end of the instru- 





cfvwf™? GfOMfr/fMAMCO. 

T/fOMAS GAUGE 



Fig. 97. — Shows how to measure the circumference of the pylorodilator with Thomas's 
gauge. 

ment is held tight by something that drags along with it, not 
being able to escape it. It is not permissible to use much 
force. The balloon is then made somewhat smaller by pull- 
ing the piston of the syringe and thus deflating it slightly. 
Tin- is repeatedly done until the end of the dilator by a slight 
pull passes through the pylorus. Using a graduated syringe 
one notes the amount of air in cubic centimetres existing in 
the balloon during its passage through the pylorus. Within 
the stomach there is no resistance felt when drawing the dilator 
until the cardia is reached. Here the dilator should be entirely 
deflated and withdrawn, which is accomplished without trouble. 



390 



DISEASES OF THE STOMACH. 



Should, however, a resistance be encountered at the introitus 
oesophagi, the patient should swallow and while his larynx 
moves upward the instrument is gently removed without ap- 
plying any force. 




Fig. 98. — A. X-ray photograph of patient, E. F., lying with abdomen on the plate with 
pyloric dilator in the digestive tract and a bismuth-buttermilk mixture in the stomach. 
The end of the pyloric dilator is distinctly visible in the descending portion of the duode- 
num; right above it is the balloon filled with air, which appears as a bright oval area. 
The stomach is outlined as a dark area. 



Wash the instrument, dry it off with a towel — now fill it 
with the same amount of air contained in the balloon when 
passing the pylorus and measure the circumference, best with. 
Thomas's adaptable gauge (Fig. 97). 



ISCHOCHYMIA. 391 

The accompanying radiograms (Figs. 98, 99, 100) * of patient 
E. F. illustrate the position of the dilator dining the entire pro- 
cedure: A. Endpiece with balloon in the descending portion of 
the duodenum: B. the balloon just in front of the pylorus 
pushing the latter toward the left; C. balloon after its passage 
through the pylorus, lying in the cardiac portion of the 
stomach. The stretching may be repeated once a week. 

The results obtained were uniformly good. 

I will describe two of the cases treated by stretching of the 
pylorus more fully. 

Case I.— March 31st, 1910. Mrs F. R ,46 years old, was 

always well until three months ago when she began to be troubled 
with nausea, vomiting, constipation, headache, pain in upper 
abdomen, insomnia, and anorexia. She lost considerably in 
flesh. Her physician sent her to the hospital with a probable 
diagnosis of cancer of the stomach. Status praesens: Patient is 
a somewhat emaciated elderly woman; there are no eruptions or 
glandular enlargements. Pupils are equal and react to light. 
Her tongue is coated; her lungs, heart, and pulse are normal. 
The abdomen is soft, tympanitic and tender in the epigastrium. 
The stomach is considerably dilated, extending to about three 
fingers below the navel. Washing of the stomach in the fasting 
state shows the presence of food from the previous day. The 
urine is negative. The blood is normal, the stomach contents 
show free HC1 36, total acidity 60, also the presence of food 
remnants from the day before, no lactic acid and no blood. 
Treatment by gastric lavage is ordered every other day — the 
pylorus is stretched by means of the dilator on April 9th and April 
16th. After stretching the pylorus the stomach began to be 
empty in the fasting condition. Patient could eat a variety of 
food without distress and gradually recovered. 

Case. II. — November 6th, 1910. Geo. B. T., aged sixty-seven, 
began to suffer 15 years ago from indigestion and gave up 
smoking and drinking on that account. Five years later 
patient consulted me for his affection. At this time his main 

1 I am indebted to Dr. L. G. Cole for these beautifully executed radio- 
grams. 



392 DISEASES OF THE STOMACH. 

trouble was pain in the stomach about two hours after eat- 
ing. Since this time he has been treated for his stomach 
trouble at different times. At present his main complaint is a 
feeling of great pain in his stomach and gas pains immediately 
after eating. He has to belch a gread deal and has constantly a 
sour, bitter taste in his mouth. The pains are of a severe type 




Fig. 99.— B. Same as Fig. 98, a few minutes later, after pulling the dilator up, in front of 
the pylorus. The dilator with the inflated balloon is seen oustide of the stomach, in the 
duodenum, invaginating the pylorus slightly into the stomach. 

and patient cannot sleep. Every few days he vomits a large 
quantity. He then feels very much relieved. At no time has 
he to his knowledge vomited blood. During the last illness he 
lost 24 pounds in weight. His stools are slightly costive and 
have never contained mucus or blood. At one time he had 
considerable mucus in his vomitus but no more. 



ISCHOCHYMIA. 



393 



Present Condition. — The stomach is greatly dilated, extending 
to the pubis. The pylorus can be indistinctly felt as an oval 
tumor of walnut size. There are distinct peristaltic waves visi- 
ble, moving from left to right, covering the left side of the abdo- 
men. The stomach is examined in the fasting condition: 700 
c.c. of a watery fluid mixed with food are obtained; HC1 + ; acidity 





Fig. 100 — C. Same as Fig. 98. a few minutes still later, after having pulled the dilator 
through the pylorus into the stomach. The end of the dilator can be seen in the cardiac 
portion of the stomach. 

=96. Occult blood is present. Patient is kept abed on a 
strictly liquid diet and on the magnesia and bismuth medication. 
The vomiting continues, also the severe pain. Patient is at times 
bo weak that he can hardly talk. Washing of the stomach is 
performed every day. The amount of residue fluctuates be- 
tween 300-700 c.c. and patient is wretched. The duodenal 



394 DISEASES OF THE STOMACH. 

bucket is introduced at night and is withdrawn the following 
morning in the fasting condition. It returned filled with bile 
and lower end of the thread attached to the bucket was golden 
yellow for 12 cm. This showed that the pylorus was permeable, 
The pyloric dilator was then inserted at 6 p.m. and left in the 
digestive tract until the following morning. The pylorus was 
then stretched on November 2, 1910. Patient stopped vomiting 
and could eat better without distress. On November 3 the 
stomach contained 90 c.c. of fluid mixed with some food. On the 
following days, however, it was empty. Patient began to par- 
take of solid food. About ten days later there was a relapse and 
patient began to vomit and felt distressed. The peristaltic rest- 
lessness of the somach likewise returned. The pyloric dilator was 
again applied and immediate improvement followed, the stom- 
ach emptying normally and patient being able to enjoy eating. 
He has lately gained ten pounds in weight. In the latter case 
the stretching of the pylorus was almost a life-saving procedure. 
For the patient was in no fit condition to be operated and 
would apparently have succumbed had his pylorus not been 
stretched. This procedure acted like magic. The vomiting 
ceased; the stomach emptied itself over night and all distress 
disappeared. 

Cancerous stenosis of the pylorus hardly admits of any treat- 
ment. Condurango given when there is anorexia, and chloral 
hydrate (a tablespoonful of a three-per-cent. solution every 
two to three hours) when pains exist, as has been recommended 
by Ewald, are the most reliable and efficient medicaments. 

In ischochymia due to atony of the gastric muscles the treat- 
ment should consist of lavage, direct faradization of the stom- 
ach, and the administration of frequent but light meals. 

Complications. 

Tetany. — The occurrence of tonic and clonic spasms in the 
flexors of the arms, in the muscles of the calf, and in the mus- 
cles of the abdomen as a complication of "dilatation of the 



ISCHOCHYMIA. 395 

stomach'' (ischochynria) was first pointed out by E. Neumann 1 
and shortly afterward by Kussmaul. 2 Frequently the muscles 
of the face, of the jaws, and of the neck are likewise affected 
by the spasmodic contractions. The eyes are tinned upward 
and occasionally emprost hot onus of short duration occurs. 
The crampy contractions are painful; consciousness is either 
undisturbed, partly disturbed, or entirely absent. In one of 
KussmauTs cases, which was published by Gassner, 3 the at- 
tacks had a distinctly epileptiform character. Several cases of 
this complication, which have been described mostly under the 
name of tetany, have been published by Leven, 4 Dujardin 
Beaumetz, 5 Hanot, Midler, 6 Gerhardt, 7 Renvers, 8 Bouveret and 
Dew, 9 Ewald, 10 Albu, 11 Boas, 12 and Fleiner. 13 Real tetany is 
characterized by the sudden appearance of mostly bilateral 
tonic contractions of the muscles, beginning at the fingers and 
toes and progressing thence centripetally. The flexor muscles 
are principally affected, and the hand usually assumes a posi- 
tion which has been characterized by Trousseau as the obstet- 
rical hand. Only in rare instances are the extensor muscles 
also affected. As a rule, the knees are bent and the toes 
turned downward, while the heel is turned upward and some- 
what outward (pes equinus). The muscles of the femur and 
the thigh are only very rarely involved. The duration of the 
attacks may vary from five minutes to several hours. The fol- 

1 E. Xeumann: Deutsche Klinik, 1861. 

2 Kussmaul: Deutsch. Arch. f. klin. Med., 1869, Bd. vi. 

3 Gassner: Inaug. Dissert., Strasburg, 1878. 

4 Leven: Gaz. med. de Paris, 1881, p. 646. 

5 Dujardin Beaumetz: L'Union medic, 1884, Xos. 15 and 18. 
•Muller: Charite Annalen, Bd. 13, 1886. 

7 Gerhardt: Berl. klin. Wochenschr., 1886, Xo. 36, and 1888, No. 4. 
8 Renvers: Gesellschaft der Charite Aerzte, 1887. 
8 Bouveret et Devic: Rev. de medicine, 1892, p. 48. 

10 Ewald: Berl. klin. Wochenschr., 1894, Xo. 2. 

11 Albu: Berl. klin. Wochenschr., 1894, Xo. 2. 

12 Boas: loc. tit., 107. 

13 Flemer: Arch. f. Yerdauungskrank., Bd. i., Heft 3. 



396 DISEASES OF THE STOMACH. 

lowing symptoms, which exist for some time after the attacks, 
arc characteristic of tetany: 

1. Compression of the main nerves or blood-vessels of the 
affected extremities for one to two minutes will produce an 
attack (Trousseau); 2. The electrical irritability of the nerves 
and muscles is greatly increased (Erb); 3. The mechanical ir- 
ritability of many nerves of the extremities, and especially of 
the facialis, is increased. Tapping with a finger in the region 
of the facial nerve produces quick contractions of the corre- 
sponding muscles. Kneading of the face from top to bottom 
evokes contractions of the subjacent muscles (Chvostek). 

The prognosis of tetany is quite bad. In the cases collected 
by Bouveret and Devic there was a mortality of 70 per cent. 

It seems that this complication is of quite rare occurrence, 
for all the cases mentioned in literature scarcely exceed thirty. 
Tet any-like convulsions and epileptiform attacks with loss of 
consciousness are met with far more frequently. According to 
my experience, the latter complications occur not only in cases 
of chronic ischochymia, but also in other affections of the 
stomach. 

Thus I have observed one case in a man, 28 years old, who 
suffered for a great many years from a chronic gastric catarrh. 
In August, 1895, during a hot spell, he was obliged to drink 
large quantities of ice-w T ater. At that time he began to suffer 
from attacks of tetany, alternating with epileptiform convul- 
sions and loss of consciousness. During an attack of tetany 
the patient would notice that his arms and legs became con- 
tracted against his will and would remain in this condition for 
about ten minutes, he being perfectly conscious, but unable to 
change the assumed position of the affected extremities. 

The epileptiform attacks would begin with a premonitory 
stage of pain in the gastric region and a restless condition 
which would last only a short while. Thereupon the patient 
would lose his consciousness entirely and convulsions of all the 



ISCHOCHYMIA. 397 

muscles in the body would ensue. He would remain in this 
state from twenty to forty minutes, would frequently bite his 
tongue, and after awakening usually had no idea of what had 
happened. The patient had such attacks of either tetany or 
epileptiform convulsions once or twice a week, and felt utterly 
prostrated for a day or two after their occurrence. He also 
complained of a very disagreeable taste in the mouth between 
the attacks. On examining the stomach in the fasting condi- 
tion, I found that it was perfectly empty. One hour after a 
test breakfast free hydrochloric acid was present, but the de- 
gree of acidity was somewhat diminished. Under lavage and 
a general tonic treatment, the patient's condition improved and 
the attacks became milder in form and appeared at much 
longer intervals; thus for a period of six weeks the patient had 
no attacks whatever. The attacks sometimes occurred with- 
out any apparent cause, sometimes, however, they could be 
referred to some gross dietetic error; thus, for instance, the 
patient once took a very large piece of salted herring with 
bread and cheese at 12 o'clock at night before retiring. He 
awoke at two and called his brother, who slept in the adjoining 
room, telling him of his restless condition and of the painful 
sensation within his stomach, and a few minutes later was 
seized with a severe convulsive attack, which lasted for half 
an hour, and during which he again severely bit his tongue. 

I have observed a similar case of epileptiform attacks in 
which there was likewise no ischochymia, but hyperchlorhydria 
and erosions of the stomach. In this case, however, the at- 
tacks, as a rule, appeared after an accidental overloading of 
the -tomach, alcoholic drinks apparently playing a great part 
therein. In a third case I likewise noticed epileptiform at- 
tacks in a lady of 40 years of age, who suffered from chronic 
ischochymia, due to a benignant stenosis of the pylorus. 

The prognosis of these epileptiform attacks seems to be \''av 
more favorable than that of real tetany, for in none of the 



398 DISEASES OF THE STOMACH. 

throe cases mentioned have the attacks thus far resulted in a 
fatal issue. 

With regard to the etiology of either tetany or the epilepti- 
form attacks accompanying severe gastric disorders, three 
theories have been expounded: 1. One theory has been given 
by Kussmaul, explaining the symptoms of tetany and similar 
conditions by the great loss of fluids to which the system has 
been subjected, for this condition is most frequently found in 
patients who have vomited for a long time and in this way 
lost a great deal of liquid, in consequence of which the blood 
has been much thickened, while the nerves and all other tis- 
sues have become thoroughly dry. The thirst which is met 
with in these patients and the greatly diminished urinary ex- 
cretion speak in favor of this view. This theory has lately 
gained a warm supporter in Fleiner, who pointed out that in 
most of these conditions of stenosis of the pylorus, besides the 
slight quantity of liquid which is able to pass from the stom- 
ach into the small intestine, there is often a state of hyper- 
secretion, owing to which abundant quantities of gastric juice 
are poured into its cavity. The latter circumstance increases 
the great deficiency of water in the system. 

2. The second theory, advanced by Germain See, 1 explains 
these tonic and clonic convulsions as a reflex action from the 
nerves of the stomach. Friedrich Miiller is also in favor of 
this view, for the two following reasons: First, tetany is occa- 
sionally met with in cases in which there is no considerable 
loss of fluid, as for instance in cases of intestinal worms. Sec- 
ondly, Miiller was able to produce such an attack of tetany 
in one of his patients by striking his epigastrium. 

3. The third theory explains tetany and similar conditions 
on the basis of auto-intoxication. In cases of ischochymia, 
many processes of fermentation and decomposition exist, and 
these give rise to the production of toxic elements, which are 

1 Germain See: Bull, de l'Acad. de m£d., 1888. 



ISCHOCHYMIA. 399 

liable to give rise to the above described symptoms. Ger- 
hardt, Bagiiiski/ Paliard, 2 Loeb, 3 Bouveret and Devic, Ewald, 
Heim, 4 Albu, Schlesinger, 5 and Kulneff 6 are all firm believers 
in this auto-intoxication theory. Bouveret and Devic, and 
likewise Kulneff, have been able to obtain from the gastric 
contents of patients with chronic ischochymia by Brieger's 
method (extraction with alcohol and precipitating with chlo- 
ride of mercury) toxic products of the diamine group. Ewald 
and Jacobsohn, and later Albu, have obtained from the urine 
of a patient affected with tetany an alkaloidal substance (the 
picrin salt). This substance usually appeared in the mine 
during the attacks of tetany only and not during the intervals. 
Bouveret and Devic are of the opinion that the toxic 
products develop much quicker in cases of hyperchlorydria if 
alcoholics have been indulged in. Although the auto-intoxi- 
cation theory seems to be the most plausible, its verification 
remains to be demonstrated. 

1 Bagniski: Arch. f. Kinderheilk., Bd. vii., 1886. 
2 Paliard: Rev. de medic, 1888, p. 406. 
3 Loeb: Deutsch. Arch. f. klin. Med., Bd. 46, p. 98. 
4 Heim: Inaug. Diss., Bonn, 1893. 

5 Schlesinger: Berl. klin. Wochenschr., 1894, Xo. 9. 

6 Kulneff: Berl. klin. Wochenschr., 1891, Xo. 44. 



CHAPTER XII. 

ABNORMAL CONDITIONS WITH REFERENCE TO 

THE SIZE, SHAPE, AND POSITION OF 

THE STOMACH. 

Abnormalities in the Size of the Stomach. 

In the normal state, the size or capacity of the stomach 
varies within wide limits, and this is more marked in patho- 
logical conditions. The following figures of capacity were 
obtained by Ziemssen 1 as the result of a large number of post- 
mortem examinations of the stomachs of persons of about the 
same size who during life had never manifested signs of diges- 
tive troubles. The largest stomach of these held 1,680 c.c. 
(or fifty-six ounces), the smallest 250 c.c. (eight ounces); 
the other figures ranged between these limits. While some 
years ago any stomach of very large size was considered as 
diseased, Ewald first pointed out that the organ, no matter 
how great its capacity, may still be able to work perfectly and 
satisfactorily. He therefore suggested that an acquired or 
congenital large stomach with normal functions should be des- 
ignated as "megastria." A very large stomach causing mani- 
fest digestive disturbances is generally spoken of as a dilated 
stomach (dilation of the stomach, gastrectasia) . The most ex- 
tensive degrees of gastric dilatation are found in cases of ob- 
struction of the pylorus. 

Angustatio ventriculi denotes an extremely small stomach. 
In very marked degrees of this condition the stomach may 
have a capacity of hardly an egg in size, and may appear even 

1 Ziemssen, cited from C. A. Ewald: "Diseases of the Stomach," p. 110. 

400 



ABNORMALITIES IN THE POSITION OF THE STOMACH. 401 

narrower than the duodenum (Haller). 1 Angustatio ventriculi 
is generally found in most cases of oesophageal or cardiac stric- 
tures (principally cancerous); occasionally, however, it occurs 
alone in cirrhosis ventriculi. 

Abnormalities in the Shape of the Stomach. 

The shape of the stomach is occasionally found altered, 
caused by cicatricial changes after extensive ulcers. The 
hour-glass form is one which gives rise to grave disturbances 
and can frequently be recognized during life. Inflation with 
carbonic-acid gas shows the hour-glass shape of the organ; 
lavage six to seven hours after a meal will occasionally fail to 
remove all the contents. After the wash water has come out 
clear for a time there may occur a sudden admixture of chyme. 
The best means of recognizing this condition is an X-ray exami- 
nation of the stomach after the ingestion of bismuth by the 
fluoroscope or by a photographic plate. The symptoms 
resemble those of ischochymia. The treatment is principally 
surgical. 

Abnormalities in the Position of the Stomach. 

The abnormal positions of the stomach may be either con- 
genital or acquired. Among the congenital abnormalities we 
would mention the transposition of the stomach in the thoracic 
cavity, which occurs if there is a partial or a complete defect 
at the diaphragm. The stomach is found to be situated on the 
right side of the abdomen (pyloric portion to the left) in cases 
of general transposition of the viscera. Both these anomalies 
are extremely rare. Among acquired anomalies a vertical 
position of the stomach is occasionally found. The pylorus is 
then situated much lower and farther to the left than normally. 
This condition is mostly found in women and can be easily 
recognized either by the gastrodiaphane or by inflation of the 

1 Haller: "Elem. Physiol.," Lib. xix., Sect. 1, §3. 
26 



402 DISEASES OF THE STOMACH. 

stomach, which reveals a lengthy but narrow configuration, 
its horizontal diameter not extending to the right of the linea 
alba. 

Descensus ventriculi or gastroptosis (low position of the 
stomach) is the most frequent anomaly; it usually occurs in 
connection with ptosis of several other intestinal organs, and 
will therefore be best described under enteroptosis, or Glenard's 
disease. 

Enteroptosis, or Glenard's Disease. 

Definition. — Downward displacement of the stomach, right 
kidney, and other organs of the abdominal cavity, attended 
with digestive disturbances. 

General Remarks. — Descent of the stomach as well as of 
other abdominal organs was described many years ago by Vir- 
chow, Leube, Landau, and other authors; yet to Glenard 1 
must be awarded the credit of having first sufficiently empha- 
sized the importance of this condition, of having recognized its 
clinical significance, and established it as a distinct affection. 

The idea which led the French physician to the discovery of 
the disease designated by his name was the fact that the whole 
digestive tract, which from the mouth to the anus is ten or 
fifteen times longer than a straight line connecting both points, 
is arranged in the form of different baldachins suspended on 
six loops 2 by means of ligaments at the posterior wall of the 
abdomen. 

The zigzag direction of the loops offers the possibility of too 
great a bend, sometimes at such an acute angle that it causee 
obstruction to the passage of the ingesta or secretions at ths 
six main points of fixation. This might occur at the gastro- 

l Y. Gtenard: Lyon MeU, 1885, p. 450. 

3 (1) Anse gastrique; (2) anse duod6nale; (3) anse ileo-colique; (4) anse 
colique transverse; (4a) costo sous-pylorique; (5) sous-pyloro-costale ; (6) 
anse colo-sigmoidale. 



ENTEROPTOSIS, OR GLENARDS DISEASE. 403 

duodenal, duodeno-jejunal, or transverse/ sigmoido-rectal 
curvatures. 

The ligaments are not all of equal strength and the points of 
fixation of several of them are especialty weak. This is true 
of the gastro-duodenal and the transverse colon ligaments. 
Thus, from a theoretical point of view, it is apparent that the 
possibility exists that the weak ligaments may give way under 
favorable conditions, and that a falling of that part of the 
intestine may result. This would naturally exert increased 
traction on the next fixation point, and might cause an obstruc- 
tion to the passage of the contents of the intestine, or, in other 
words, a partial enterostenosis. In forty autopsies Glenard 
several times found the colon trans versum displaced and sten- 
osed. He recognized that these changes in the anatomical 
position must give rise to troubles, which should be considered 
dependent upon this condition. In examining all his patients 
with digestive troubles, he found that there were many so- 
called ''nervous dyspeptics" in whom he could discover, by a 
thorough investigation of the abdomen, that some abnormal 
position of the intestines existed. 

Etiology. — It is generally accepted that the corset plays a 
predominant part in the causation of the downward displace- 
ment of the abdominal organs; confinement is also believed to 
be a great factor of this disorder. But besides these two points, 
which refer only to the female sex, there are some other condi- 
tions which likewise predispose to enteroptosis and have 
reference to both sexes, namely, acute diseases of a grave nature 
and protracted ailments accompanied by a considerable loss of 
flesh. 

Stiller 2 assumes that enteroptosis represents a congenital 
anomaly, since he also found in these cases a floating tenth rib. 

1 "Colique sous-costal droit," "colique sous-costal gauche," "sous- 
pylorique du transverse." 

2 Stiller: Arch. f. Ycr<lauiint;skrankh., 189G, vol. ii., p. 285. 



404 DISEASES OF THE STOMACH. 

As is well known, normally only the eleventh and twelfth ribs 
are floating, while the tenth rib is fixed by means of its cartilage 
to the thorax. This anomaly Stiller designated as the " costal 
stigma." His assertions, however, that the costal stigma 
represents a positive sign of enteroptosis have not been sub- 
stantiated. 

Although in many instances the weakness of the abdominal 
walls takes its origin in a congenital disposition to this anomaly, 
there is no doubt that cases are met with in which a congenital 
factor certainly does not come into play. To the latter category 
belong those instances of enteroptosis which develop after 
rather sudden great losses of flesh, no matter what be their 
cause, and also after abrupt changes in the volume of the 
abdominal cavity. 

Enteroptosis is found quite frequently, especially among 
women. In order to give a clear illustration of this fact, I 
take at random a number of patients recorded in my private 
day book for the months of January and April, 1896. In the 
month of January I saw 57 male patients with gastric disturb- 
ances; among them were 4 with a distinct enteroptosis and right 
movable kidney (third and fourth degrees); the number of 
women with the same disturbances amounted to 33, and 13 had 
distinct enteroptosis with right movable kidney. The month 
of April showed similar figures: Number of male patients, 84; 
enteroptosis with movable kidney, 5. Number of females, 59; 
enteroptosis with movable kidney, 19. The figures of these two 
months put together show: Number of male patients, 141; 
enteroptosis with movable kidney, 9. Number of female 
patients, 92; enteroptosis with movable kidney, 32. We find 
the percentage of enteroptosis to be 6 . 2 among the male patients 
with digestive disorders, while in the females similarly afflicted 
we find the percentage to be 34.8. The great frequency of 
enteroptosis which has been noted by Glenard is fully sustained 
by the figures just given. , 



EXTEROPTOSIS, OR GLEXARD'S DISEASE. 405 

Inasmuch as statistical material gains in value the greater 
the number from which the deductions are made, I 1 took the 
trouble to examine all my private patients of the year 1900, 
with regard to the occurrence of visceral ptoses. The greater 
contingent of my cases consisted of patients with digestive 
disorders. The total number amounted to 1,912 patients — 
1 .080 males, 832 females. Among these there were encountered 
347 cases with ptoses of the abdominal viscera, 70 among the 
men and 277 among the women. Among these there were 240 
cases of enteroptosis, 20 in men and 220 in women 

In most of the cases the enteroptosis was accompanied by a 
movable kidney, namely, 212 — 18 in men and 194 in women. 
The assertion of Trastour, " Movable kidney is the habitual 
satellite of enteroptosis," appears thus to be correct. Among 
the cases of enteroptosis with movable kidney, 23 had also a 
descent of the liver — 3 men and 20 women. Enteroptosis with 
floating liver, unaccompanied by movable kidney, was noted 
in 12 cases — 1 in a man and 11 in women. Enteroptosis alone 
(the kidneys and liver being in their normal places, the only 
symptoms being a descent of the stomach and a strong pulsa- 
tion of the abdominal aorta) was found in 15 cases — 1 male and 
14 female. Movable kidney alone, not accompanied by general 
enteroptosis, was encountered 57 times — 21 in males and 36 
in females. Floating liver alone was found in 39 cases — 25 
male and 14 female. 

Symptomatology. — It is well known that enteroptosis may 
exist without giving rise to any symptoms whatever. In 
most instances, however, various morbid manifestations arc en- 
countered. The latter are not always due to enteroptosis alone, 
but rather to coexisting disorders of the digestive tract. The 
following are the symptoms which must be assigned to the 
enteroptosis alone: The patient often complains of some faint- 

Mi\ Einhorn: "Remarks on Enteroptosis." Medical Record, April 
13th, 1901. 



406 DISEASES OF THE STOMACH. 

ness or a certain weakness after rising. There is frequently a 
feeling of considerable fatigue after slight exertion, principally 
after walking. In women this is also combined with pronounced 
backache. A feeling of weight is occasionally experienced 
in the lower half of the abdomen, while a dragging sensation is 
felt in the epigastric region. Flatulence is often encountered; 
constipation is present in most of the cases, and frequent mictu- 
rition in a considerable number. Aside from these direct 
symptoms, it is safe to say that any disease of the digestive 
tract, complicating enteroptosis, does not show the same tend- 
ency to yield to the usual remedies as normally. The abnormal 
position of the abdominal viscera produces a weakening effect 
upon the resisting power of the organism and its energy in 
combating maladies, especially when the latter exist in them. 
This explains why the greater part of patients with enteroptosis 
are troubled with one or the other variety of stomach or bowel 
disorder, or both. Cases of enteroptosis, lasting a long period, 
frequently lead to pronounced anaemia, in consequence of sub- 
nutrition. The latter gives rise to a host of nervous manifesta- 
tions (neurasthenia). 

As a good instance of the subjective symptoms of enter- 
optosis, I describe the following case: 

December 2d, 1900. — Moses C , 30 years old, has been 

suffering for a long time from constipation. He has had this 
since childhood, as far back as he can remember. He has never 
vomited, but suffers from distress in the stomach. This organ 
feels as though suspended and filled with a heavy weight. Often 
it feels as if it were bobbing up and down, quivering once or 
twice. He declares that he is conscious of having a stomach. 
He can eat everything, but sometimes even a glassful of water 
will produce a feeling of distress. He sleeps well, but has no 
appetite, and is troubled a good deal with flatulence. On rising 
he feels bad, having sometimes nausea. 

Present Condition. — A very nervous, slim young man. The 
heart and lungs are normal. The stomach reaches two fingers 



ENTEROPTOSIS, OR GLENARD'S DISEASE. 407 

below the navel; the liver is somewhat descended, about one 
finger below the right costal margin. The right kidney, on deep 
inspiration, can be palpated in its lower third. Chemical exami- 
nation of stomach contents one hour after the test breakfast 
shows the presence of free HC1 and a total acidity of 80. Weight, 
one hundred and thirteen pounds. 

Objective Symptoms. — Patients with enteroptosis are, as a 
rule, thin and slender, and often appear younger than they 
really are. The abdominal walls are generally flaccid, and the 
abdominal cavity appears to be too commodious for its con- 
tents. Palpation is extremely easily executed in these patients, 
there being, as a rule, no rigidity of the muscles. When the 
patient stands, the lower part of the abdomen shows a round 
protrusion, which begins at the navel, while the epigastric 
region presents a caved-in appearance. This is principally 
found in female patients. In the latter, a pendulous abdomen 
may be encountered, especially in those who have had children. 
In the same class of patients diastases of the recti muscles are 
occasionally met with. 

The stomach occupies a low position — gastroptosis — that means 
the greater as well as the lesser curvature has been pushed 
downward. The abnormal position of the stomach can be 
easily demonstrated by the following three procedures: 

1. Splashing sound. 2. Inflation of the stomach with gas. 
3. Gastrodiaphany. The most convenient and easiest means 
is the splashing sound. On tapping, principally upon the left 
side of the abdomen below the margin of the ribs, in a partly 
filled condition of the stomach, there will be no sound audible 
immediately below the ribs, while somewhat farther down in 
the region of the navel, above and below it, the splashing can 
be distinctly heard. The area over which this splash can be 
produced will indicate the position of the stomach. Inflation of 
the stomach with gas, as well as gastrodiaphany, will certainly 
distinctly show the descent of the stomach; but these pro- 



408 DISEASES OF THE STOMACH. 

fcedures, being a little more complicated, should be reserved for 
doubtful cases. 

Strong pulsation of the abdominal aorta is frequently en- 
countered, and is probably due to the partial uncovering of this 
vessel by the slipping down of the stomach. The transverse 
colon, the caecum, and part of the ascending colon, as well as. 
the sigmoid flexure, can often be distinctly palpated. The 
transverse colon is frequently found in these cases as a 
ribbon-like body running horizontally above the navel. 
This Glenard designated as " corde colique transverse," and con- 
cluded from the size of the cord, which is considerably smaller 
than we should expect the colon to be, that there is a condition 
of enterostenosis, or a narrowing of the bowel. Ewald and 
others are of the opinion that the ribbon-like body felt does not 
represent the colon, but the pancreas. My own view, however, 
coincides with that of Glenard. For in some instances the 
corde colique is found in the region of the navel, or even some- 
what below it — where the pancreas never exists — and again 
occasionally in palpating this transverse band a gurgling sound 
is heard. Furthermore, it can sometimes be traced to the 
ascending colon. 

Movable kidney is another essential symptom of enteroptosis. 
The recognition of the movable kidney is quite easy. It is only 
necessary to practise palpation with both hands, putting one 
hand on the back of patient behind the lumbar region, while the 
other hand is held flat below the margin of the false ribs covering 
the lower outside angle of the abdomen. By having the 
patient inspire deeply, the kidney, if movable, is felt to slip 
between both hands; slight pressure with the hand on the lum- 
bar region will facilitate the recognition of an existing movable 
kidney. 

While Israel is of the opinion that on deep inspiration even a 
normal kidney may be partly felt by this method of examina- 
tion, Glenard considers all cases in which the kidney can be per- 



EXTEROPTOSIS, OR GLEXARDS DISEASE. 409 

reived by palpation as abnormal. This writer distinguishes 
four degrees of movable kidney : 

First degree oj nephroptosis: The lower part of the kidney can 
be palpated during deep inspiration; during expiration the 
kidney slips back to its place and it is impossible to arrest it. 

Second degree: The greater part of the kidney can be palpated 
and it can also be arrested, but its superior margin cannot be 
felt. 

Third degree: The superior margin of the kidney can be 
reached on deep inspiration. 

Fourth degree: The whole kidney is accessible to palpation 
even during expiration (the movable or wandering kidney of 
the older writers). 

Symptoms due to movable kidney, as such, are the 
following: 

1. A feeling of traction and weight in the abdomen. 

2. Quite violent palpitation in the epigastrium (pulsation of 
the abdominal aorta). 

3. The disturbances are usually more pronounced when the 
patient stands or walks, and disappear in the recumbent 
position. 

4. Frequent urination, occasionally attended with slight 
burning. 

5. Pains in the sacral region after slight exertion. 

6. In women the discomfort is usually increased at the time 
of menstruation, and considerable improvement manifests 
itself during pregnane}'. 

These six symptoms need not always be present; they may all 
absent, or occur separately. 

The right kidney is often found movable, occasionally both 
kidneys are, seldom the left kidney, and still more rarely the 
spleen. The liver may also partly or wholly descend, and thus 
a more or less considerable surface of this organ will be acces- 
sible to palpation. 



410 DISEASES OF THE STOMACH. 

Cases of floating liver 1 can be divided with regard to their 
symptoms into the following five groups: 

1. Cases unaccompanied by symptoms, in which the floating 
liver gives rise to no disturbances. 

2. Dyspeptic cases, with indefinite digestive disturbances in 
conjunction with a feeling of weakness and certain other 
nervous symptoms. 

3. Cases of hepatalgia, in which almost constantly pains are 
present on the right side of the abdomen (hepatic region), which 
often radiate toward the back and shoulder blades. These 
pains frequently subside in the recumbent posture. In many 
instances sensations of a drawing and tearing character are 
present. 

4. Cases of hepatic colic, in which colicky attacks occur 
similar to gall-stones colics. In these no icterus is commonly 
present, although it may appear in rare instances. 

5. Asthmatic cases, in which a feeling of fulness and constric- 
tion in the upper abdominal region, associated with slight 
dyspnoea, is especially prominent. 

Cardioptosis 2 is often found present in association with 
floating liver. 

In females a prolapse of the uterus is not infrequently found. 
Apparent tumors of the abdomen 3 are occasionally encountered 
in patients with enteroptosis. 

Diagnosis. — The diagnosis of enteroptosis is quite easy. It 
is only necessary to think of this condition, and it is not likely 
to escape detection. The subjective symptoms above detailed, 
in conjunction with the result of a thorough examination of the 
abdomen by the usual physical methods, will reveal the presence 

1 Max Einhorn: "Floating Liver and Its Clinical Significance." Medical 
Record, September 16th, 1899. 

2 Max Einhorn: "Cardioptosis and Its Association with Floating Liver." 
Medical Record, April 25th, 1903. 

8 Max Einhorn: "On Apparent Tumors of the Abdomen." Medical 
Record, November 24th, 1900. 



ENTEROPTOSIS, OR GLEXARD'S DISEASE. 411 

of enteroptosis. Another auxiliary in diagnosis of this condi- 
tion is the so-called Glenard's "belt test." The physician, 
standing behind the patient, encircles the lower part of the 
abdomen of the latter with both his hands, at the same time 
supporting and partly lifting it. The patient is now asked if 
this procedure gives him relief. If so, it speaks in favor of 
the presence of enteroptosis. 

Prognosis. — The prognosis of enteroptosis is good. When 
appropriate treatment is instituted, an amelioration in the con- 
dition of the patient quickly takes place. Whether a full 
restitutio ad integrum can occur is not yet definitely settled. 
With regard to this point it is interesting to note that, as early 
as 1883, Henderson 1 reported a perfect cure in a patient with 
movable kidney, within the short period of two and a half 
months. His remarks are very appropriate even now: "Nowa- 
days, when the surgeon boldly invades the great cavities of the 
body — clearing out tubercular vomicae, freeing an impacted 
gall duct, stitching a displaced kidney to the lumbar muscles, 
and in other ways threatening the position of the physician in 
his own domain — it behooves the latter, in friendly rivalry, as 
well as for the general good, to show that his art does not end 
with the diagnosis of abnormal conditions, but also extends to 
their successful removal." From my own experience I would 
say that a perfect cure of enteroptosis is possible. I know of 
positive cures — that is to say, the stomach has returned to its 
normal position, and a movable kidney has disappeared — in 
more than a dozen cases of my own. 2 As a good instance of 
such a cure, I describe the following case, which was very 
recently under my observation: 

Miss Mary G , 20 years old, was troubled with her digestive 

J F. Henderson: "A Case of Movable Kidney Permanently Cured." 
The Glasgow Medical Journal, vol. x\\. 1883, p. 329. 

2 Max Einhora: "Cases of Enteroptosis and Cardioptosis with Return 

to the Normal. " New York .Medical Journal, April loth, 1905. 



412 DISEASES OF THE STOMACH. 

organs as far back as she could remember. She had always suf- 
fered from severe constipation. Here appetite was poor; she 
frequently had slight pains some time after meals. She often 
felt somewhat faint some time after rising, and was hardly able 
to walk any considerable distance on account of the great fatigue 
and backaches which overcame her. On examination I found 
that the chest organs were intact. The stomach extended four 
fingers' widths below the navel, while the lesser curvature could 
be found two fingers above the navel. Both kidneys were 
movable, the right in the fourth and the left in the second degree. 
After being treated for about two months with ample feeding, 
intragastric faradization, and an abdominal bandage, she 
steadily improved. I will also add that during this time she 
took a great deal of outdoor exercise (bicycling, rowing, walking, 
golfing, etc.). In this short period she gained fifteen pounds in 
weight, felt well in every respect, was strong, could eat every- 
thing, and her bowels moved quite regularly. Another examina- 
tion of the abdomen showed that the stomach now extended 
only down to one finger above the navel, while neither of the kid- 
neys could be palpated. 

Treatment. — In treating enteroptosis all measures will be of 
value which serve to strengthen the entire organism, and 
especially the abdominal muscles, and remove existing dis- 
turbances of the stomach or bowel. Besides, we must try to 
exert a beneficial influence on the position of the abdominal 
organs by mechanically reducing the volume of the abdominal 
cavity and thus lifting the stomach up. The means for strength- 
ening the organism are well known and consist in suitable 
nutrition, gymnastics and out-of-door exercise, cold ablutions, 
and rubbings. For the purpose of strengthening the abdominal 
organs in enteroptosis we may make use of: (1) Dietetic treat- 
ment; (2) electricity; (3) hydro therapeutics; (4) massage; (5) 
gymnastics. 

Dietetic Treatment. — In all cases of enteroptosis it is best to 
diminish the amount of fluids taken, i.e., care must be taken 
that the patient does not drink water, tea, coffee, or other 



EXTEROPTOSIS, OR GLENARD'S DISEASE. 413 

beverages (beer, wine) in too large quantities (more than eight 
ounces at a time). Thorough mastication, the avoidance of 
strongly spiced foods, short rest (one-quarter of an hour) after 
meals are of benefit. In every case of enteroptosis we must 
individualize to a large extent in selecting the proper kind of 
diet. If, as is usually the case, we have to deal with emaciated 
anaemic persons, we must resort to forced feeding, i.e., we must 
try to introduce into the body large amounts of nutritive 
material, so that overnutrition and subsequent increase of 
tissues result. In these cases it is advisable to have the patients 
take five or six meals daily. The three principal meals (break- 
fast, dinner, supper) should be composed of the usual foods. 
The two or three intermediate meals should consist of milk 
(eight ounces) and buttered bread (one or two slices). Instead 
of pure milk, milk with chocolate or coffee, or milk punch, or 
kumyss, or thick sour milk, etc., may be given. In regard to 
the amount of food, I usually tell the patients to eat as much as 
their neighbors at table, adding only that the quantity of butter 
to be consumed daily should be at least one-quarter of a pound. 
If we have to do with people in a condition of good nutrition, 
we certainly would not make any change in the quantity of 
food to which they are accustomed. If there are marked dys- 
peptic disturbances, and the state of the stomach in regard to 
its secretion is known, the diet may be adjusted accordingly. 
If hyperchlorhydria is present, large amounts of albuminous 
foods and less of starchy substances ought to be given; whereas 
in cases of diminished secretion or achylia only a little meat and 
abundance of the carbohydrates are permissible. The exclu- 
sion of a whole group of food-stuffs, either albuminous orstarchy 
substances, is never a wise measure, because we are dealing 
with conditions lasting a long time, and a diet deficient even in 
but one of the three chief groups will certainly be deleterious. 
In cases of enteroptosis with obstinate constipation the so- 
called laxative foods (fruits, vegetables, salads) play a more 



414 DISEASES OF THE STOMACH. 

important role, while in the presence of a tendency to diarrhoea 
all fruits and cold drinks must be excluded. 

Electricity. — Besides static electricity (franklinization) and 
general faradization, which serve to increase muscular tone, I 
attach much importance to intragastric electrical treatment. 
The latter is especially indicated in marked functional disturb- 
ances of the gastro-intestinal apparatus. Marked atony of the 
stomach, as usually present in enteroptosis, is favorably 
influenced by this treatment. Faradization is most frequently 
used intragastrically; only in cases of obstinate pains or nausea 
galvanism seems to be of greater value. This electrical treat- 
ment of the stomach contributes materially to the removal of 
the disturbances of this organ, thus affording a possibility for 
better nutrition and strengthening of the whole body. It 
serves, therefore, not only for the relief of the gastric disturb- 
ances, but also indirectly aids in the removal of the 
enteroptosis. 

Hydrotherapeutic Measures. — In connection with the general 
hydrotherapeutic treatment the abdominal muscles as well as 
the digestive tract may be favorably influenced by direct 
applications of water. The use of the Schott douche, lasting 
from one to two minutes, over the abdomen, especially in the 
course of the colon, is at times accompanied by good results. 
Priessnitz compresses, applied during the night over the abdo- 
men, are of value if enteroptosis is complicated with painful 
symptoms in the abdominal region. These compresses may 
be used for three to four weeks or longer. The drinking of large 
quantities of plain or mineral waters seems to be contraindicated 
in this affection. Sometimes, however, moderate amounts of 
w r ater may be taken one hour before breakfast. This is of 
especial advantage in cases of enteroptosis, complicated with 
constipation. A glassful of cold water, or, in hyperchlorhydria, 
of an alkaline water (Vichy), or Carlsbad water (warm) is 
frequently of benefit in obstinate constipation. 



ENTEROPTOSIS, OR GLEXARD'S DISEASE. 415 

Massage. — Besides general massage of the body, light knead- 
ing of the abdomen may be practised. In cases of constipation 
it is advisable to employ massage, especially over the colon. 
In such cases, provided the patients are not too much run down, 
auto-massage of the abdomen by means of a cannon-ball may 
be applied. 

In all cases, however, massage of the abdomen must be care- 
fully executed, since from a rough and injudicious application 
inflammatory conditions of the peritoneum may result. I 
distinctly remember two cases of this kind. Both were women 
in whom at their own request abdominal massage had been 
practised by experienced masseurs for the relief of constipation. 
In the one case, after the second seance, a severe pain developed 
in the right iliac region, with a rise of temperature to 103.4° F. 
The fever continued two days, to disappear only with the 
amelioration of the symptoms. In the other case, after several 
applications of massage, intense pains, both in the right and 
left iliac regions, developed, and persisted nearly a week, con- 
fining the patient to her bed. Fever was, however, not present. 
In greatly run-down individuals it is not generally advisable to 
use abdominal massage. 

In cases of enteroptosis with movable kidney, accompanied 
by painful sensations, it is best to combine general abdominal 
massage with massage of the kidney. The latter procedure, 
according to Reibmayr, 1 is executed as follows: 

"The patient lies in the same position as in abdominal 
ma --age, the abdominal muscles being relaxed as far as possible. 
The operator sits at the side which is to be massaged and places 
his flattened left hand, if it is the right kidney (his right hand 
in case of the left kidney), on the lumbar region, so that the 
kidney rests upon his fingers. The thumb i., supported in front 
by the lower costal margin. With the right hand he now 

1 A. Reibmayr: "Die Unterleibsmassage," Leipzig und Wien, 1889, S. 
30. 



416 DISEASES OF THE STOMACH. 

attempts gradually to reach the kidney through the abdominal 
walls by means of the finger tips, and after having grasped the 
kidney between both hands to knead and stroke the organ 
gently." 

A peculiar form of massage is that employed by Brandt in 
cases of nephroptosis. The patient lies in the lithotomy 
position, the physician at his side, facing the patient. After 
having replaced the kidney, he places both his hands in front 
under the margin of the ribs and guides them with constant 
vibratory movements backward and upward, allowing his finger 
tips to slip around to the back of the trunk. The motion is 
facilitated by the patient lifting his buttocks somewhat. 

In connection with massage, special gymnastics as well as 
a suitable position of the patient may be employed. 

Special Gymnastics. — The abdominal muscles may be 
strengthened by calling them into frequent and strong activity. 
For this purpose rotation of the trunk toward both sides while 
standing still, as well as raising the upper part of the body 
while lying, and similar exercises may be of benefit. These 
may be continued for about three to six minutes. 

Position of Patient. — A suitable position of the patient has 
been frequently utilized successfully in treating enteroptosis. 
Lying in bed is of value in preventing the ptosis of the abdomi- 
nal organs. It would be still better to elevate the buttocks, 
throwing the abdominal organs from the lower part of the 
abdomen to the upper regions and keeping them there. Con- 
stant rest in bed may be enj oined in grave cases for two to three 
weeks and longer, combined with elevation of the buttocks for 
several hours during the day. 

Similar in action to lying on the back, which produces a 
natural replacement of the descended abdominal organs from 
below upward, is the use of mechanical means for this purpose. 

Means Serving to Decrease the Abdominal Space and to Crowd 
the Abdominal Organs Upward. — The relaxed abdominal walls 



ENTEROPTOSIS, OR GLENARD'S DISEASE. 



417 



found in enteroptosis can be strengthened by means of suitable 
abdominal bandages. Glenard has strongly emphasized this 
point and constructed a bandage for this purpose (Fig. 101). 
There are many other similar bandages in use (Figs. 102, 103, 



Q. TIEMANN & Co.. N. Y. 




Fig. 101. — Glenard's Bandage. 

104). In ordering an abdominal bandage it is of prime impor- 
tance to fit it well so that it will accomplish the desired purpose, 
viz., keeping the lower part of the abdomen well supported and 
lifting it somewhat upward. In patients who do not have a 
pendulous abdomen nor much fat it is important to have 




Fig. 102. — Hard-rubber Abdominal Supporter. 

fenestra in the bandage over the iliac crests, so as to avoid 
pressure on these points, and also to attach straps running 
between the legs, as otherwise the bandage is liable to be dis- 
placed upward (Fig. 105). As the straps cause annoyance to 

27 



41S 



DISEASES OF THE STOMACH. 



the patient I have devised a new kind of bandage resembling 
(See Fig. 105.) 



tights. 





Fig. 103. 



Fig. 104. 



At times in cases of very flat abdomen the bandage may have 

to be provided in addition with a 
suitable pad covering the lower 
abdomen, in order to increase the 
mechanical pressure. 

In such cases A. Rose's 1 method 
of covering the abdomen with ad- 
hesive plaster strips may be em- 
ployed. The plaster cannot, how- 
ever, generally supplant a bandage, 
as the constant presence of the 
plaster strips in contact with the 
skin is a source of some discom- 
fort. 

Modified corsets supporting the 
lower part of the abdomen (Gal- 

Fig. 105. — Bandage with Holes over x N 

the Iliac Crests, and Straps around the lailt's and La GrecqUe's COrsets) 
Legs, as generally used by the writer. t t 

are likewise of benefit. 
Medicinal Treatment. — Of medicaments, iron and arsenic are 
often indicated in anaemic conditions, while the bromides may 




*A. Rose: "Gastroptosis." The Post-Graduate, March, 1900. 



EXTEROPTOSIS, OR GLEXARD'S DISEASE. 419 

be given to allay great nervousness. All the digestive disturb- 
ances should be managed according to the general rules. This 
applies also to the constipation which is so frequently present 
in enteroptosis. Laxatives, however, should not be habitually 
resorted to. nor is there any need of laxative treatment in cases 
in winch the bowels are regular. 

After having enumerated the procedures used in the treat- 
ment of enteroptosis, I would once more lay stress upon the 
essential points. These are a suitable, sufficient nutrition, 
general hygienic mode of life, and the wearing of a well-fitting 
bandage. 



CHAPTER XIII. 

NERVOUS AFFECTIONS OF THE STOMACH. 

General Remarks. 

Deviations from the normal process of gastric digestion not 
based upon pathologico-anatomical changes are considered as 
gastric neuroses. We are accustomed to ascribe the different 
functions of the stomach to the action of special nerves. 
Although physiological experiments have not as yet enabled us 
to discover special nerves governing secretion, motion, or sensi- 
bility of the organ, still clinically many facts speak in favor of 
such an assumption. The neuroses of the stomach are also 
occasionally designated as "functional disturbances." The 
different gastric neuroses may appear either separately or, 
occasionally, in combination with each other. As a rule, 
these neuroses occur most frequently in women, especially 
between the ages of seventeen and forty; in men also the 
middle period of life shows a predilection for these disturb- 
ances. As a predisposing factor for these neuroses the fol- 
lowing conditions must be recognized: severe mental exer- 
tions, worry, unusual excitement, sexual excesses. The 
recognition of the neurosis is not always very easy. The 
principal point of importance is the exclusion of any organic 
lesion of the organ. The following symptoms, which frequently 
recur in gastric neuroses, have been especially well described 
by Boas, 1 and will facilitate the recognition of the nervous ele- 
ment of the affections in question. 

1. The entire nervous system shows more or less deviation 

1 Boas: "Specielle Diagnostik und Therapie der Magenkrankheiten," 
2te Auflage, p. 204. 

420 



SENSORY GASTRIC NEUROSES. 421 

from the normal. There ma}' be present headache, insomnia, 
conditions of depression, or, on the other hand, excitation, 
increased sensitiveness. Objectively there may be an increase 
or diminution of the reflexes of the skin and tendons, hyper- 
aesthesia at some, paresthesia or anaesthesia at other places. 
Frequently there exists constant or intermittent polyuria. The 
general condition may be good or various degrees of emaciation 
may be present. 

2. The digestive system is characterized by a condition of 
"labile gastro-intestinal function." The subjective symptoms 
are not always necessarily connected with the act of digestion. 
The digestive complaints are usually independent of the quality 
and quantity of the ingested food. Dietetic errors are, as a 
rule, not followed by any aggravation of symptoms; while the 
character of food does not have any influence upon the severity 
of the symptoms, there are occasionally some other factors in 
the way of climate and surroundings which play an important 
part in the amelioration or deterioration of the condition. 
Objectively changes in the condition of gastric secretion and of 
the motor function of the stomach as well as of the intestines 
frequently occur. Thus complete anacidity may alternate 
during a short period with normal secretion. The condition 
of the motor functions of the stomach frequently changes. 
The state of the bowels is also very variable; thus constipation 
frequently alternates with diarrhoea, or, at a time when the 
bowels are regular, an acute diarrhoea may suddenly appear. 

According to Rosenthal, 1 the neuroses of the stomach are 
best divided into: (1) Sensory, (2) motor, and (3) secretory 
neuroses of the stomach. 

Sensory Gastric Neuroses. 
For the sake of greater clearness sensory gastric neuroses are 

1 If. Rosenthal: " Magenneurosen und Magenkatarrh," Wien und Leip- 
zig. 1886. 



422 DISEASES OF THE STOMACH. 

best divided into two main groups: (a) Comprising abnor- 
mal sensations of a more or less general character; (b) special 
sensations emanating from the stomach itself. 

(a) Abnormal Sensations of a General Character. 

The need for food makes itself felt through the sensation 
of hunger, the need for drink through that of thirst. The ner- 
vous centre for these sensations appears to be located in the 
medulla oblongata (R. Ewald 1 and Rosenthal). The stomach 
is the organ into which all substances satisfying hunger and 
thirst are introduced. The act of satisfying the sensation of 
hunger with relish is called "appetite." Normally there ap- 
pears in man a slight feeling of hunger at the usual meal- 
time. A man relishes the food he takes until at the end of 
the meal a feeling of satiety appears. The latter may be best 
characterized by noting the point at which the sensation of 
hunger has entirely disappeared. On going beyond this point 
to any extent — i.e., by continuing to introduce further food 
into the organ — a sensation of weight and tightness around 
the stomach develops. This can then be considered almost as 
a normal process, and is the way the stomach responds to in- 
terference with its habitual mode of work. 

The time at which hunger appears is physiologically variable 
and depends upon the time persons are accustomed to take 
their meals. On this account there are people who feel hun- 
gry only twice a day, as they are in the habit of taking only 
two meals daily; others again who feel hungry about every 
three hours, as they are accustomed to take five meals a day, 
and so on. Although the ingestion of food may sometimes lead 
to some variations in the time at which hunger is experienced 
— so that a man who is in the habit of taking a light meal at 
a certain period during the day, after having partaken of a 
much heavier meal than customary, will perhaps not feel hun- 

1 R. Ewald: Cited from C. A. Ewald, I. c, p. 380. 



BULIMIA. 423 

gry at his next meal — this is of less consequence than the in- 
fluence of the time at winch the meals are ordinarily taken. 
Thus every one knows that if he has been accustomed to take 
his lunch, for instance, at one o'clock, the hungry feeling will 
appear at one, and if not satisfied within a certain period of 
time (half an hour to an hour), then very frequently it will 
disappear to return at the next mealtime. 

Pathologically we find that the above-named sensations may 
exist either in an exaggerated form, or may be greatly dimin- 
ished or even absent. 

Bulimia. 

Bulimia (/3or? % ox, Ai^o's, hunger) or cynorexia (*uW, dog, 
opetL$, appetite), or hyperorexia, denotes a condition in 
which the feeling of hunger is enhanced, appearing more fre- 
quently and in a more intense degree than in the normal state. 
Bulimia may exist alone as a primary affection or may be as- 
sociated with various other disorders, and is then considered 
as a secondary affection. Thus ulcer of the stomach, hyper- 
chlorhydria. cancer of the stomach, intestinal troubles, tape- 
worm, pancreatic affections, Graves' disease, hysteria and 
neurasthenia, and tumors of the brain are all liable to be com- 
plicated with bulimia. 

Symptomatology. — Bulimia may appear periodically and last 
only a short time (a few days) or may exist chronically and last 
for months or even years. The periodical form is usually char- 
acterized by much greater intensity than the chronic. An at- 
tack of bulimia may be described as follows: In the midst of 
perfect euphoria, a feeling of intense hunger overcomes the 
patient with a persistent desire to satisfy it. This hungry sen- 
sation i< associated with a gnawing feeling in the stomach, 
and the utmost fear and anxiety, as if something alarming 
were going to happen. If the feeling of hunger is not satis- 
fied very quickly, then severe headache and trembling of the 



424 DISEASES OF THE STOMACH. 

body or even fainting spells ma}' occur. The patient in such 
a condition, as a rule, disregards conventionalities and tries to 
obtain whatever food he can, in order to overcome this painful 
craving of his stomach. Generally a small quantity of nour- 
ishment is sufficient to arrest the attack, sometimes, however, 
large quantities of food have to be taken. Thus Peyer 1 de- 
scribes the case of a woman who was suddenly seized with an 
attack of bulimia, so that she could not return home from the 
house of a neighbor whom she was visiting. In forty-five min- 
utes she ravenously devoured three pints of milk, twenty-three 
eggs, and two pints of strong wine. After this meal she be- 
came quieter, went to sleep, and awoke perfectly well on the 
next day. 

The primary cause of bulimia appears to be a derangement 
of the nervous apparatus for the hunger sensation. This de- 
rangement may be either central or peripheral. Hypermotility 
was found by Leo 2 in a patient troubled with bulimia; but 
although present in some instances it is by no means a con- 
stant symptom. Thus Ewald 3 reports a case of bulimia in 
which the motor function of the stomach was perfectly normal. 

Treatment. — The treatment should always be directed against 
the primary cause of the trouble. Thus helminthiasis must be 
removed by extract of male fern. Hyperchlorhydria should be 
treated by carbonate of soda, diabetes by a meat diet, and so 
on. Cases of neurasthenia or hysteria will have to be treated 
as such. The following means at our command may be di- 
rected against bulimia as a distinct disorder: 

Very frequent light meals (every two hours). 

The bromides should be given in large doses, twice daily, as 
for instance potassium or sodium bromide, in doses of 1.5 gm. 



1 A. Peyer: " Beitrag zur Kenntniss der Neurosen des Magens und des 
Darms." Correspondenzbl. schweizer Aerzte, 1888, No. 20. 

2 Leo: " Verhandlungen des Vereins fur innere Medicin," Berlin, 1889. 
3 C. A. Ewald: I c, p. 379. 



PAROREXIA. 425 

(gr. xx. \ or bromide of strontium 12 gm. to 60 c.c. pepper- 
mint water, one teaspoonful twice daily, or — 

R Amnion, brom.r 

Sodii brom aa 8.0 o ij. 

Aq. menth. pip 60.0 § ij. 

S. One teaspoonful twice daily. 

Rosenthal 1 recommends the use of cocaine in doses of 3 to 5 
cgm. twice daily. 

Opium or codeine, in doses of 3 to 4 cgm. (gr. ss.) three 
times daily, may be advantageously employed. 

Arsenic is also of value. 

R Liq. potassii arsenitis. 

Aq. menth. pip., aa 5.0 3 jss. 

S. Six drops three times daily. 

A change of climate, sojourn in the mountains or at the sea- 
shore, is frequently beneficial. 

Parorexia {Perversion of Appetite). 

The appetite is sometimes manifested for special and pecu- 
liar kinds of food, and to this condition the name parorexia 
has been applied. There exist three degrees of parorexia: 1. 
Malacia: an increased desire for spiced food-stuffs, as. for in- 
stance, mustard, salad, vinegar, green fruits, etc. 2. Pica: the 
appetite manifests itself for substances which are not in reality 
foods, thus for coal, ashes, chalk, earth, sand, insects. 3. Al- 
lotriopharjia: there seems to be a craving for substances which 
are decidedly disgusting and harmful, as for instance fecal 
matter, needles, pins, etc. 

While the first form (malacia) is met with in many disturb- 
ances of the stomach or in different neurotic conditions of the 
m (neurasthenia), the latter two conditions appear only 
in severe forms of hysteria, and more frequently in idiots and 
lunatics. 

1 Rosenthal: I. c. 



426 DISEASES OF THE STOMACH. 

Polyphagia. 

Polyphagia denotes a condition in which excessive amounts 
of food have to be taken in order to satisfy the feeling of hun- 
ger. Polyphagia is met with in the same conditions as bulimia, 
and especially in the following disorders: Cancer of the pan- 
creas or spleen, fistulous opening of the gall bladder, diabetes, 
and some tumors of the brain. But polyphagia may also be 
observed as a primary affection in neurotic persons. Like buli- 
mia, polyphagia either appears in the form of attacks of short 
duration or may exist as a chronic trouble. The amount of 
nourishment which may be devoured by the patient during 
such an attack of polyphagia is sometimes enormous. Thus 
Rosenthal reports the case of a woman, twenty-eight years old, 
who devoured at one meal an entire large fried goose and a 
big portion of bread. Bouveret 1 mentions a case reported by 
Percy : The patient, Tarare by name, when seventeen years old 
could partake of one hundred pounds of meat in twenty-four 
hours. 

Akoria. 

By akoria is designated the absence of the sensation of 
satiety (icopewvui, I feel satiated). The main symptom of 
this condition consists in the loss of the feeling a person nor- 
mally experiences at the end of the meal which tells him that 
he has had enough. The patient with akoria never knows 
when to stop eating. Frequently akoria is found combined 
with polyphagia, but not always. It is met with in similar 
conditions as bulimia and polyphagia, neurasthenics and hys- 
terics forming the large majority of cases. 

Nervous Anorexia. 

Under the term anorexia (ope&s, appetite) is understood a 
complete absence of the sensation of hunger, combined with 

1 L. Bouveret: "Traite des Maladies de l'Estomac," Paris, 1893, p. 654. 



NERVOUS AXOREXIA. 427 

loss of appetite. While anorexia is met with in almost all or- 
ganic as well as functional disorders of the stomach, "nervous 
anorexia" may at times appear as a primary affection, unas- 
sociated with the conditions just mentioned. The cause of this 
primary anorexia may be either a depressed condition of the 
hunger centre or. according to Rosenthal, a kind of hyperes- 
thesia of the gastric mucous membrane. As etiological factors 
are frequently found great mental depression, as after a death 
in the family, worry, anxiety, fright, etc. 

Symptomatology. — At first the patient complains of loss of 
appetite and begins to eat less. As a rule, all kinds of meat are 
first discarded from the bill of fare. Later on bread, butter, 
and afterward most solid foods are avoided and the patient 
subsists only on a small quantity of milk and some soup. For 
quite a while the patients apparently maintain their healthy 
appearance and do not even seem to lose in weight. The small 
quantities of food the patient takes are now still further reduced. 
Even the encouragement on the part of the family to take more 
nourishment fails to have any effect; the patient, as a rule, 
obstinately refusing to do so. It was Sollier 1 who laid particu- 
lar stress upon this symptom, and suggested designating this 
condition by the name of "sitieirgy" (o-Ttos, food, and £py<», 
refuse). At this stage the patients lose considerably in weight 
and begin to look emaciated, have cold extremities, a slow pulse 
(50 to 60) and reduced temperature (95 to 96° F.); they grow 
anaemic and weak, and very soon are hardly able to leave their 
The appearance of such a patient in this stage of the 
- very similar to that of a consumptive. The face is 
pale, the eyes sunken, the skin dry, the extremities slightly 
cyanosed, and the abdomen retracted. If the patient still con- 
tinues to refuse food, the condition may terminate fatally. 

9 Uier: Revue de m£decine, aout, 1891. 



428 DISEASES OF THE STOMACH. 

Such cases of nervous anorexia ending in death have been 
reported by Gull, 1 Charcot, 2 Rosenthal, 3 and others. 

Rosenthal's case was as follows: The patient, female, seven- 
teen years old, had suffered for eighteen months from anorexia. 
After this period she took only 30 to 40 gm. of milk per day. 
The patient became emaciated and looked like a skeleton. She 
could not sleep and could not leave her bed. Isolation of the 
patient or forced alimentation could not be employed under the 
existing circumstances. Symptoms of rapidly progressing 
inanition appeared, in connection with shortness of breath, 
dysphagia, and alalia, all indicating anaemia of the bulbar 
centres, the case terminating fatally. 

Diagnosis. — After the development of nervous symptoms no 
difficulty is encountered in making the diagnosis of anorexia. 
It is necessary first of all to exclude organic affections of the 
stomach. The early stage of tuberculosis may at times be 
mistaken for nervous anorexia, especially if there exists no 
cough or if tubercle bacilli are absent in the sputum. One 
point, which is quite valuable in making the diagnosis of nerv- 
ous anorexia, is the circumstance that patients with the latter 
condition are not in any way alarmed about their loss of appe- 
tite, while anorexia existing in organic disorders of the stomach, 
like cancer, etc., evokes fear and anxiety. 

Treatment. — In the early stage of the disease the treatment 
is quite easy. It is merely necessary to impress the patient 
with the idea that he must take sufficient food. The meals 
should be taken at regulated periods. The patient should be 
given food without any previous questioning as to whether he 
would like it or not. At meal-times he should be encouraged 
to take his entire portion. A liberal variety of foods is also 
of importance. In the way of medicines most of the bitter 

1 Gull: Lancet, 1868. 

2 Charcot: "(Euvres completes," t. iii., p. 240. 

3 Rosenthal: I. c. 



NERVOUS AXOREXIA. 429 

tonics, which stimulate the appetite, are indicated. Thus mix 
vomica, in the form of the tincture, may be given in doses of ten 
drops three times daily, or fluidextract of condurango, twenty 
drops three times daily. Boas recommends fluidextract of 
Peruvian bark, one teaspoonful three times daily. Orexinum 
basicum in doses of 2 to 3 dcgm., in wafers three times daily, is 
also useful. All these stomachics should be given about one- 
quarter of an hour before meals. 

The longer the disease has existed the more difficult it be- 
comes to combat it successfully. If it is already of long stand- 
ing and has led to a high degree of emaciation and other pro- 
nounced symptoms of inanition, then treatment at the home 
of the patient is hardly ever successful. Charcot first laid stress 
upon the importance of isolating the patient from his surround- 
ings. This plan of treatment has been still further advanced 
by Weir Mitchell 1 in this country, and this method is known as 
the Weir Mitchell rest cure. The principle of this cure con- 
sists first in isolation of the patient from his family; secondly, 
in strict supervision by the physician, and by a constant attend- 
ant : thirdly, in ample feeding, so that a state of hypernutrition 
may be established; fourthly, in the application of massage and 
electricity, which may be considered as adjuncts to the above. 

In cases in which food is absolutely refused, even after isola- 
tion, forced alimentation or gavage (feeding by means of the 
tube) becomes necessary. Frequently after having nourished 
the patient by artificial means for a few days, he gains the con- 
viction that his stomach is able to digest food and then begins 
to eat spontaneously. Good fresh air and an organic iron prep- 
aration like Gude's peptomangan or Pizzala's or Dietrich's 
albuminate of iron or Boehringer's ferratin may be advanta- 
-ly administered, especially after the patient has begun to 
improve. Arsenic may also be administered, either alone or 
in conjunction with the above-mentioned iron preparations; 

1 Weir Mitchell: "Fat and Blood," Philadelphia, 1884. 



430 DISEASES OF THE STOMACH. 

thus Fowler's solution, two or three drops three times daily in 
water, or Levico or Roncegno mineral waters may be given, 
one to two tablespoonfuls daily, or cacodylate of sodium, half 
a grain t. i. d. As a rule, the patent should not leave the sani- 
tarium until he has regained his former weight. In the latter 
instance there is no danger of relapses. 

Sitophobia. 1 

By the term sitophobia we understand a condition in which 
too little food is taken on account of fear. This fear relates to 
pains or disagreeable sensations in the digestive apparatus 
arising after meals. To avoid these, patients prefer not to eat, 
or rather to eat as little as possible. Sitophobia is most com- 
mon in chronic affections of the digestive system, accompanied 
by pains (gastralgia and enteralgia). These are usually as- 
cribed by the patient to various foods, and in order to avoid the 
pains, they exclude at first the coarser and later even easily 
digestible articles from their dietary, taking finally only small 
quantities of milk or broths. Sometimes sitophobia arises in 
consequence of an abnormal sensibility of the gastric mucous 
membrane (hyperesthesia ventriculi). This is but another 
variety of the cases just described; for even if in hyperesthesia 
of the stomach no severe pains are experienced, yet the ingestion 
of food causes disagreeable sensations which the patient is 
anxious to avoid. 

A further group is formed by those cases in which patients 
from false ideas, in the absence of pain, avoid food or limit its 
amount. Thus especially sufferers from intestinal disorders, 2 
afflicted with constipation or diarrhoea, are afraid to eat heartily, 
because they think that the condition would be aggravated. 

1 Max Einhorn: "Sitophobia and Inanition, and their Treatment. " 
American Journal of the Med. Sciences, August, 1903. 

2 Sitophobia of Enteric Origin. Journal of the American Medical Asso- 
ciation, June 15, 1901. 



SITOPHOBIA. 431 

To this class also belong all cases in which the patient for some 
reason or other on account of a certain ailment eats too little 
in quantity or variety, as, for instance, gouty people avoiding 
all meats, obese persons who do not take fats or carbohydrates, 
thereby injuring the organism. 

Sitophobia, if left alone, leads to a partial, sometimes nearly 
total, inanition. A consideration of these conditions is, there- 
fore, not out of place here. 

Inanition means loss of strength owing to deficient nutrition. 
This expression was first used by Chossat 1 to designate the 
atrophy resulting from total abstinence. According to Samuel, 2 
we must distinguish between complete and incomplete inanition. 

Complete inanition of short duration (twelve to twenty-four 
hours) is often noted, as, for instance, in travellers who do not 
find an opportunity to obtain food during a voyage; also on fast 
days that are observed by many persons for religious reasons. 

Signs of weakness and various nervous symptoms (pains in 
the neck, severe headaches, vertigo) develop early and are 
especially marked after severe exertions. Prolonged periods 
of fasting are undergone either by shipwrecked people or by 
special professional fasters. The latter have been made the 
subject of important scientific investigations during the last 
twenty to thirty years. Our knowledge of metabolism during 
inanition is now almost complete, thanks to the labors of Zuntz 
and Lehmann, 3 Luciani, 4 and others. 

It has been shown that during complete inanition the organ- 
ism takes up as much oxygen as during normal rest — i.e., after 
digestion is completed, for during the latter state an increased 
amount of oxygen is utilized owing to the augmented activity 
of the digestive apparatus. During inanition the body con- 

1 Recherches experimentales sur l'inanition, 1835. 

2 Eulenburg's Encycl. der Med., Bd. x. p. 320. 

3 Bericht iiber die Eigebnisse des an Cotti ausgefuhrten Hungerver- 
suches. Berl. klin. Wochenschr., 1887, p. 42. 

* Das Hungern., 1890. 



432 DISEASES OF THE STOMACH. 

sumes its own substance in order to maintain its temperature 
and its chief functions. It lives on its own flesh and fat and 
does not economize any more than normally. 

According to von Noorden, 1 the body during total abstinence 
burns up about 1 gramme of albumin and 3 . 5 grammes of fat 
per day and kilo of bodily weight. Samuel describes the 
symptoms of complete inanition as follows: "The feeling of 
hunger is most intense after twenty hours, and disappears after 
that; the feeling of thirst, however, remains until death. The 
mucous membranes become dry; weariness, weakness, and 
faintness are pronounced. The loss of weight is continuous. 
The mental faculties remain clear until the last. Sub finem 
vitae albumin and mucin appear in the urine. The temperature 
sinks to 30° C. during the last twenty-four hours, and death 
occurs amid extreme prostration, deep coma, at times delirium 
and convulsions. During absolute abstinence death supervenes 
between the twelfth and twentieth days. If water is taken, 
life may be sustained for forty to seventy days. Forty per cent, 
of the bodily weight is usually lost before death. " 

Incomplete inanition or subnutrition is frequently met with. 
In relatively few cases we have to deal with conditions in which 
the organism is unable to utilize larger amounts of food (car- 
cinoma cardiac seu ventriculi, seu pylori — extreme degrees of 
benign stenosis of the pylorus, infectious diseases during the 
febrile period). In most cases of subnutrition, however, we 
have to deal with conditions in which the organism would be 
perfectly capable of utilizing food if it were supplied to it. 

These are, therefore, conditions in which amelioration is 
possible. 

Subnutrition begins as soon as the usual amount of food 
is diminished. The daily physiological quantity of food is 
about 100 to 130 grammes of albumin, 70 to 120 grammes of fat, 
350 to 400 grammes of carbohydrates, 2500 to 3000 grammes of 

1 Berl. Klinik., 1893, Heft 55, p. 1. 



SITOPHOBIA. 433 

water, and 1-i to 32 grammes of inorganic salts. Besides we 
inhale 744 grammes of air. The total amount of new material 
that is daily ingested is about 4 kilos, or about one-fifteenth of 
the total bodily weight. Expressed in calories, the bod}^ needs 
daily for each kilo about 35 to 40 calories during rest and 40 
to 50 during hard work. If less food is taken an incomplete 
inanition results, which manifests itself by anaemia and loss of 
weight. Incomplete inanition, qualitatively — as, for instance, 
total abstinence from water, even such as occurs in solid food 
— leads, according to Samuel, to death just as quickly as 
complete inanition. On a purely albuminous diet the body 
fat disappears, and on a diet consisting of fats or carbohydrates 
alone the bodily albumin diminishes. A diet deficient in salts 
is badly borne. Digestive disturbances arise and nervous 
symptoms (trembling, muscular weakness) and death follow. 

In practice we meet less often with a one-sided subnutrition 
(one deficient in a qualitative way) than with general subnutri- 
tion. The latter is encountered in the greater number of dys- 
peptics. I would like to cite here some examples from my 
practice as I meet them every week, in fact almost daily, in 
order to show how much less food dyspeptics take than the 
physiologically required quantity: 

Case I. (March 15, 1903).— Mrs. Sadie M., aged thirty-eight 
years, complains for the last six years of pains about half an 
hour after meals, and much belching. She weighed formerly 168 
pounds, and has decreased to 100 pounds in five years. She 
feels week, without energy, sleeps poorly, and has pains after 
meals. She fears to eat on account of pain. During the last 
four months she has lived as follows: 

8 a. m. One cup of milk (200 c.c.) 128 calories. 

One slice of stale bread (30 g.) without butter ... 64 calories. 

12 if. One-quarter pound of steak 125 calories' 

One potato (25 g.) 22 cal<»ri< -s. 

< Occasionally a half slice of stale bread 32 calories. 

6 P. m. One-eighth pound of steak 62 calories. 

Two dices of stale bread 128 calorics* 

The patient took daily per kilo weight 12 1/2 calories. 561 calories. 
28 



434 DISEASES OF THE STOMACH. 

Case II. (September 24, 1902). — Mrs. F. H., aged thirty-eight 
years, complained for two years of a feeling of constriction in 
the upper abdominal region. Appetite was increased, bowels 
were regular. During the last year she has lost twenty-five 
pounds (weighing originally 120 pounds and going down to 95 
pounds). 

She felt very weak, being hardly able to walk up stairs. Dur- 
ing the last year the bill of fare of the patient was as follows: 

8 a. M One chop (30 g.) 37 calories. 

Thin slice of bread (30 g.) 64 calories. 

Some butter (5 g.) 42 calories. 

One cup of coffee with very little milk (39 c.c.) . . 20 calories. 

10 a. m. One cup of broth (200 c.c.) 10 calories. 

12 m. Meat (100 g.) 213 calories. 

Potatoes (50 g.) 63 calories. 

String beans (30 g.) 100 calories. 

Xo bread. 

3 p. m. Cup of coffee with a teaspoonful of milk 3 calories. 

One slice of bread (30 g.) 64 calories. 

7 p. m. Steak (100 g.) 213 calories. 

One slice of bread (30 g.) 64 calories. 

A little butter (5 g) 42 calories. 

10 p. M. Claret and one cracker (10 g.) 35 calories. 

970 calories. 
The patient was therefore taking food of a nutritive ralue of 22 1/2 calories 
per kilo daily. 

Treatment. — In complete inanition lasting twenty-four hours 
or longer, the treatment consists in carefully administering 
easily digestible fluid or semifluid food in not too large amounts. 
It is quite natural that the famished are inclined to devour 
greedily any food that is accessible. If, however, they take too 
much or too coarse food it readily causes serious trouble in the 
exhausted intestinal tract. The chief duty of the physician, 
therefore, consists in proceeding with caution and restriction 
with regard to the taking of food during the first few meals. 
If after eating the exhaustion of the patient has disappeared he 
may then return to his usual mode of life. 

The treatment of incomplete inanition or subnutrition is 
altogether different. Here we must first combat sitophobia, if it 



SITOPHOBIA. 435 

exists, because otherwise the existing malnutrition can hardly 
be removed. It is important to encourage the patient to eat 
in spite of the pain. Usually the latter is in reality not so 
severe, and in nearly all cases we will succeed after a while in 
banishing the fear of food. Soon the patient can take ordinary 
nourishment. Even articles of diet which formerly caused 
severe pain are now tolerated without difficulty. The stomach, 
or rather the intestinal tract, seems to accustom itself to the 
greater demands made upon it. 

It is, of course, advisable in some cases at the beginning of 
the treatment to diminish the sensitiveness of the digestive 
apparatus by bromides or similar drugs. These medicines are, 
however, not essential, but rather bridge over the first few days 
by facilitating the carrying out of the directions in regard to 
eating. 

Another point of great importance is to improve the nutrition 
of the patient. At first we have to see that the patients take 
as much food as is necessary to maintain their equilibrium, and 
that no loss of weight occurs. This alone, however, is not 
sufficient for a complete cure; for many of these patients are 
very much run down, and while they will not lose any more 
weight with an amount of food that is just sufficient for their 
needs, they will, however, remain in their weakened condition. 
It is, therefore, very important that an increased quantity of 
food should be given, in order to make the patient gain in 
Jit. 

At first sight the accomplishment of this seems hardly pos- 
sible. In reality, however, it is not so difficult, and can easily 
be done in most dyspeptic conditions (except carcinoma of the 
stomach and bowel). 

In laying out a plan of alimentation the following points 
should be considered: The first change in diet must not be too 
great. If we have to deal with patients who have lived for a 
long time on fluid food only it is best to begin with liquid or 



436 DISEASES OF THE STOMACH. 

semisolid food, as, for instance, milk, beef-tea, raw eggs beaten 
up in milk, or broths, strained barley or oatmeal soups, gruels, 
and jellies. We must, however, see that a sufficient quantity 
of nourishment is taken. This light transitional diet should be 
increased daily by some article or other approaching more 
nearly to the ordinary bill of fare. At first soft-boiled eggs, 
zwieback, tender meat, mashed potatoes, white bread, butter; 
later, light vegetables, boiled fruits, etc., are added. 

As soon as the patients partake of the usual articles of food 
they should be instructed to eat about as much as their neigh- 
bors at table, only taking more butter (at first one-eighth, 
later one-quarter pound daily), and taking a glassful of milk 
and a slice of buttered bread regularly between meals. With a 
diet like this we succeed nearly always in obtaining an increase 
in weight. Thus in both the cases mentioned above, which 
have been picked out at random from my journal, the patients 
gained even in the first few weeks after beginning this regimen. 

The first case (Mrs. Sadie M.) gained two pounds the first 
week; the second (Mrs. F. H.) fifteen pounds in five months 
after the beginning of the treatment. 

The increase in weight, of course, continues as long as this 
excessive amount of food is taken. At the same time we find 
a general increase in bodily strength, so that patients who 
were invalids for a long time and a burden to their families 
and themselves could again resume their work and become use- 
ful members of society. 

Simultaneously with this strengthening of the body the orig- 
inal complaints, usually not due to organic lesions, can be at 
the same time removed by medical skill. Alimentotherapy, 
therefore, in these cases is the foundation of complete recovery. 

(b) Special Sensations Within the Stomach Itself. 

In its normal state the stomach barely transmits any sen- 
sations whatever to our consciousness. As a rule we lose track 



GASTRIC IDIOSYNCRASIES. 437 

of the food we take as soon as it has passed the palate and has 
been swallowed. Plain articles of food and the most delicious 
dishes are equally forgotten. Cold articles of food and warm 
beverages do not manifest their presence by any Special sen- 
sations within the stomach. Notwithstanding these facts it is 
certain that the stomach physiologically is not void of sensa- 
tion. Thus ice-water taken in large quantities on an empty 
stomach gives rise to a sensation of slight cold in the gastric 
region, especially near the scrobiculus. The faradic current 
applied within the stomach (one electrode within the organ, 
the other at the back) produces a sensation either of slight 
burning or of weight in the gastric region, provided the cur- 
rent is sufficiently strong. If it were not for these experi- 
ments, we might imagine that the stomach is an organ which 
normally does not transmit any perception to the brain. This 
fact, winch applies alike to the stomach as well as to the other 
vegetative organs of our system, is of great importance and a 
wise provision of nature; for it enables us to occupy ourselves 
with all kinds of brain work without being constantly disturbed 
by the functional processes and needs of our digestive organs. 
In contrast to the small degree of sensation which physio- 
logically exists in the stomach, the activity of the sensory ap- 
paratus may be pathologically increased and thus give rise to 
marked discomfort. 

Gastric Idiosyncrasies. 

We sometimes meet with persons who manifest an idiosyn- 
crasy toward certain substances, the ingestion of which gives 
i symptoms emanating from the alimentary tract alone 
or combined with other disorders, especially of the skin. The 
article- most apt to cause these disturbances arc certain kinds 
of fruit, especially strawberries, lobsters, soft-shell crabs, oys- 
ter-, fish; but besides these substances there are several other 
articles of food which may produce disagreeable symptoms in 



438 DISEASES OF THE STOMACH. 

certain individuals. Thus I know of several members of one 
family who betray very unpleasant symptoms (feelings of pres- 
sure, pain, belching) if a trace of onion is added in the prepa- 
ration of the food. In all these instances this is not an imag- 
inary trouble, for even if the substances mentioned are given 
in a disguised form, so that the person is unconscious of taking 
them, he will nevertheless suffer from the same symptoms. 
Generally only gastric symptoms are produced : pressure, pain, 
belching, rarely nausea and vomiting; sometimes in addition 
to these there appear eruptions on the skin, either erythema 
or urticaria. It is remarkable that in these instances the same 
individual always manifests the same symptoms upon taking 
the respective article against which he has an idiosyncrasy. 

Talma 1 described several cases in which there was an idiosyn- 
crasy against hydrochloric acid. The slightest quantities of a 
highly diluted solution of hydrochloric acid (1:750) produced 
pains within the stomach. I also have observed a case in which 
severe pains in the gastric region usually appeared one or two 
hours after meals for a period of over seven years. The analy- 
sis of the gastric contents one hour after the test breakfast 
revealed the presence of free hydrochloric acid and a degree of 
acidity of 40. As the symptoms corresponded to those found 
in hyperchlorhydria, I administered alkalies, notwithstanding 
the fact that the acidity in this case was rather diminished. 
The symptoms disappeared at once, and the patient, who was 
quite emaciated, began to gain in weight rapidly. The treat- 
ment was continued for over six months, and the improvement 
persisted. Here the pains were probably due to a kind of 
idiosyncrasy of the stomach against its own hydrochloric 
acid. 

In all these cases nothing can be done to rid the stomach 
of this peculiarity, and the persons affected must abstain from 
the offending articles, or else suffer for their indulgence. 

1 Talma: Zeitschr. f. klin. Medicin, 1884, Bd. viii., p. 407. 



HYPERESTHESIA OF THE STOMACH. 439 

Abnormal Sensations. 

Sensations of heat or more seldom of cold, of heaviness or of 
a foreign body within the stomach are present in some cases; 
and these may manifest themselves no matter whether the 
stomach be empty or not. They are not due to changes in 
the chemical condition of the gastric juice, but are merely symp- 
toms originating from the nerves of the stomach. With these 
sensations we may also class the feeling of constriction or of 
cramp within the organ and the "epigastric beating." The 
latter is sometimes due to an increased pulsation of the ab- 
dominal aorta. While in the normal state people never notice 
these pulsations, in those affected the beating sensation is very 
tormenting and is sometimes the cause of many sleepless nights. 
All these abnormal sensations are usually found in nervous 
people, neurasthenics or hysterics. 

Nausea also belongs to the abnormal sensations. Besides 
its occurrence in organic affections of the stomach it is also 
found alone, and it is then called "nervous nausea.' 7 It is met 
with in diseases of the central nervous system and in both neu- 
rasthenics and hysterics. Sometimes it is also caused by affec- 
tions in distant organs, as, for instance, the uterus or the 
ovaries, appendix, eyes (hyperopia, myopia, or astigmatism), 
and must then be considered as a reflex symptom. Nausea ap- 
pears most frequently in the fasting state, sometimes, however, 
the patient also experiences the nauseous feeling shortly after 
meals, from half an hour to an hour. The treatment should 
therefore be directed principally against the general condition. 
Sometimes the intragastric application of the galvanic current 
will greatly facilitate the cure. 

Hyperesthesia of the Stomach. 

In hyperesthesia of the stomach there is an abnormal sen- 
sitiveness of the mucous membrane even after the ingestion of 



440 DISEASES OF THE STOMACH. 

ordinary food. The patient experiences a sensation of fulness, 
of slight burning, sometimes even of pains in the gastric region 
after meals. Many organic affections of the stomach are ac- 
companied by this condition. As a primary affection it ap- 
pears most frequently, according to Rosenheim, 1 in chlorotic 
girls and women. Occasionally it is met with in people with 
a weakened constitution; thus after excesses in baecho et in 
venere, or after long periods of unsuitable dieting. 

Symptomatology. — In the mild form of hyperesthesia the pa- 
tient experiences a sensation of weight or fulness after meals. 
If the disease, however, is more pronounced, real pains occur 
after meals, and the stomach after a while may become so irri- 
table that the contact of food with the mucous membrane pro- 
duces vomiting. In the latter instance the food is partly re- 
jected soon after the meal. As a rule only a small quantity 
of the ingested food is vomited, while the greater part is 
thoroughly digested. That is the reason why in these instances 
the patient does not emaciate. If, however, the bulk of the 
food be ejected, this symptom may soon lead to grave inanition. 
The disagreeable sensations which exist in this affection fre- 
quently lead to a diminution of the quantity of food taken (a 
condition develops which is akin to "sitophobia" — fear of food), 
and in this way again the nutrition may be impaired. 

Diagnosis. — In addition to the above symptoms an examin- 
ation discloses that the gastric and epigastric regions are pain- 
ful on pressure. The secretory and motor functions of the 
stomach may be found normal or a slight degree of hyper- 
chlorhydria may exist. In the differential diagnosis we must 
exclude gastric catarrh, ulcer and erosions of the stomach, be- 
fore diagnosing hyperesthesia as such. In catarrh of the stom- 
ach the sensation of fulness or weight appears, as a rule, not 
immediately after meals, but some time afterward. Besides 
there exist in catarrh of the stomach many other symptoms 

1 Th. Rosenheim: Berl. klin. Wochenschr., 1890. 



HYPERESTHESIA OF THE STOMACH. 441 

(loss of appetite, a diminished secretion, etc.), which are not 
met with in tins condition. In ulcer of the stomach the pains 
are more violent. They are also dependent upon the quality 
of the food ingested, while in hyperesthesia the abnormal sen- 
sations are pretty much the same whether coarse substances or 
very light food be ingested. In erosions of the stomach the 
pains are also usually of a light nature, but here, as in ulcer, 
we find that the pains depend to a certain extent upon the 
quality and quantity of the food taken. Another point of im- 
portance in this condition is the results obtained after the 
washing out of the stomach in the fasting condition of the 
patient. In erosions of the stomach, as a rule, several (two 
to four) small pieces of gastric mucosa are found in the wash- 
water; in hyperesthesia tins does not occur. 

Treatment. — For the hyperesthesia occurring in chl orotic 
persons Rosenheim proposed the following treatment: The 
patient should be kept in bed, and the Priessnitz compress 
applied to the gastric region. The diet should consist at first 
of milk, to which small amounts of lime water are added, and 
which should be taken with a spoon. The addition of small 
quantities of tea or coffee to the milk is permissible. After a 
while the yolk of an egg with sugar and small quantities of 
cognac, wine jelly, scraped meat, or toasted bread are given. 
Of medicaments, Rosenheim advises the internal use of nitrate 
of silver. 

1$ Arg. nitr., 0.2 gr. iij 

Aq. dest., 100.0 5 iij. 

Half a tahlespoonful in a wineglassful of water, three times daily, 
half an hour before meals. 

When the stomach has become less irritable, the patient 
should begin cautiou.-lv with solid food and be given tonics 
like iron and arsenic, in order to restore the organism to its 
normal condition. 

In cases of hyperesthesia not originating from chlorosis the 



442 DISEASES OF THE STOMACH. 

best treatment consists in the administration of the bromides 
for a period of one or two months. 

Gastralgia. 

Synonyms. — Cardialgia, gastrospasmus, and gastrodynia. 

By the term gastralgia is designated the occurrence of at- 
tacks of pains of more or less severity in the gastric and epi- 
gastric regions. These persist for a certain period and alter- 
nate with perfectly free intervals. 

Symptomatology. — The attacks of pains rarely appear sud- 
denly. As a rule, they are preceded by short periods of vari- 
ous abnormal sensations; thus a slight feeling of nausea or of 
tension in the gastric region may exist. Increased salivation 
is also frequently one of the prodromal symptoms. Headache, 
feelings of faintness or vertigo may also precede the real at- 
tack. Very soon afterward an intense pain appears in the 
epigastric region, extending especially to the left side. There 
exist a crampy sensation and a feeling of constriction, or there 
may be a feeling of intense burning. These pains and sensa- 
tions frequently radiate to the back, to the shoulder blades, 
and over the whole abdomen. At such times the patient is 
overcome by a feeling of great anxiety. The extremities often 
grow cold, and cold perspiration appears on the forehead. The 
face is extremely pale, and bears the expression of anguish and 
anxiety. The patient frequently is unable to lie straight, and 
often assumes a bent position, so that the abdominal muscles 
are not stretched, but kept in a curved and relaxed condition. 
Sometimes the patient puts a pillow upon his abdomen and 
curls himself around it, holding it with his arms. The char- 
acter of the pulse is variable. As a rule, it is accelerated, 
sometimes, however, it is rather retarded. The gastric region 
is mostly sunken; in rare instances protruding. While this re- 
gion is sensitive to slight palpation, a more profound pressure 
does not, as a rule, cause any pain, and frequently rather re- 



GASTRALGIA. 443 

lieves the patient's suffering for a moment. The duration of 
such an attack is very variable; it may last fifteen minutes 
only or several hours. At the end of the attack the pains dis- 
appear quite suddenly, and the patient now experiences a sen- 
sation of hunger. If the attack was of short duration (half 
an hour or so) the patient does not retain any symptoms of 
malaise after it, and is able to attend to his usual work. It is 
quite different with a severe attack that has lasted several 
hours. The latter leaves a feeling of extreme weakness for 
several days, during which the patient has to remain abed. 

The frequency of these attacks is very variable, and different 
in each case. In some cases the attacks occur once in a few 
months or once in a year, while in others they appear every 
week or even every day. The attacks of idiopathic gastralgia 
do not seem to be dependent upon the quality or quantity of 
food ingested, nor to show any relation to the time of its in- 
gestion. 

Etiology. — With regard to etiology, gastralgia may be divided 
into the following forms: 

(1) Gastralgia of stomachic origin; (2) central gastralgia; 
(3) neurotic gastralgia; (4) constitutional gastralgia; (5) re- 
flex gastralgia. 

Gastralgia of Stomachic Origin. — Besides occurring in connec- 
tion with gastric affections, as, for instance, ulcer, cancer, 
hyperchlorhydria, peritonitic adhesions, gastralgia may exist as 
a primary affection of the stomach, either without any visible 
cause or after the ingestion of certain unusual or unaccustomed 
articles of food or spices; thus very strong black coffee or ice- 
cream may provoke an attack in people not accustomed to 
these substances. 

Gastralgia of Central Origin. — Diseases of the brain are very 
seldom accompanied by gastralgia. Spinal disorders are much 
more frequently associated with the latter condition. In tabes 
especially gastralgia frequently occurs. ( lharcol deserves much 



-144 DISEASES OF THE STOMACH. 

credit for having first recognized the dependence of these gas- 
tric pains upon the spinal trouble. He described these attacks 
under the name of "crises gastriques." The pathological basis 
for the latter condition was found to consist in a sclerotic de- 
generation of the vagus nucleus or the vagus trunk (Kahler, 1 
Demange. 2 Landouzy and Dejerine, 3 Oppenheim 4 ). The gas- 
tric crises differ but little from the usual gastric attacks. As 
a rule, they begin with a prodromal period of lancinating pains 
in the limbs or in both upper and lower extremities,, and also 
with excessive vomiting. The attack in many points greatly 
resembles that of continuous periodic hypersecretion, and lasts 
just about as long. Examination of the stomach contents be- 
fore and during the attack has not revealed anything charac- 
teristic (Von Xoorden 5 and Ewald 6 ). 

Besides tabes dorsalis. other lesions of the spinal cord which 
involve the vagus nucleus may also provoke gastralgia. Thus 
Leyden 7 describes it among the symptoms of subacute mye- 
litis, and Oser s in a case of pressure myelitis. This type of 
gastralgia accompanying spinal troubles appears of special im- 
portance, inasmuch as it is frequently one of the first symp- 
toms of the real trouble. The gastric crises may in some in- 
stances precede for several years the other symptoms of loco- 
motor ataxia. It is hardly necessary to mention that in all 
cases of periodic gastralgia we should examine the condition 
of the nerves and of the cord (knee reflex, Romberg's symp- 
tom, sensitiveness of the skin, and reaction of the pupils). 

Neurotic Gastralgia. — Gastralgia often occurs as one of the 

1 Kahler: Prager Zeitsch. f. Heilkunde. Bd. ii. 
• Demange: Revue de medecine, 1882. 
3 Landouzy et Dejerine: Societe de biologie, 1884. 
4 Oppenhiem: Berl. klin. "Wochenschr., 1885. 

5 C. von Xoorden: "Pathologie der gastrischen Krisen.'* Charity 
Annalen, 1880. 

6 C. A. Ewald: 7. c, p. 403. 

7 E. Leyden: Zeitschr. f. klin. Median, 1882, Bd. iv.. p. 605. 

s User: "Die Xeurosen des Magens," Wien und Leipzig, 1885. 



GASTRALGIA. 445 

symptoms of either hysteria or neurasthenia. Both conditions 
are characterized by the peculiar symptoms which, if present 
in a sufficient number, will make the diagnosis easy. Some- 
times, however, the gastralgia may exist for a long time as the 
only symptom of either neurasthenia or hysteria. It is then 
more difficult to recognize the real nature of the trouble. 

Constitutional Gastralgia. — Constitutional gastralgia is caused 
by some abnormal condition of the blood, due either to infec- 
tion, intoxication, or malnutrition. Among the infections, 
malaria is frequently the cause of intense gastralgia. The gas- 
tralgia may be associated with other symptoms of this disease, 
chills, fever, etc., or it may appear alone. It is characteristic 
of gastralgia of malarial origin to appear either every day, or 
every other day, or every third day at the same hour. I have 
frequently seen this form of gastralgia accompanied by intense 
vomiting and by a condition of hyperesthesia of the stomach 
prevailing in the intervals between the attacks. 

The intoxications causing gastralgia are very numerous. 
Thus chronic lead poisoning, an extensive use of the mercurial 
preparations, the excessive use of tobacco, frequently evoke 
typical attacks. Gout is also sometimes found to give rise to 
gastric attacks. Malnutrition, which is always associated with 
anaemia, is frequently found complicated with gastralgia, espe- 
cially in young persons (chlorosis). In these cases it is, as a 
rule, very difficult to decide whether the gastralgia is due to 
the anaemia or to a real organic trouble of the stomach, namely, 
ulcer. 

Reflex Gastralgia. — This group occurs more frequently in 
women. Reflex gastralgia may be caused by abnormal con- 
ditions in distant organs, such as the uterus, ovaries, or tubes. 
In men also diseases of the genito- urinary organs give rise to 
similar troubles. Another frequent cause of reflex gastralgia 
is errors of refraction of the eyes and an abnormal position of 
the abdominal organs. Thus enteroptosis, gastroptosis, neph- 



440 DISEASES OF THE STOMACH. 

roptosis, hepatoptosis are all occasionally the cause of gastric 
pains. Hydronephrosis has also been stated by Renvers 1 to 
be the cause of gastralgia, and I myself have observed one case 
of this kind. 

Diagnosis. — To establish the diagnosis of gastralgia it is of 
importance to exclude (1) all organic and functional diseases 
of the stomach accompanied by pain, and (2) conditions like- 
wise provoking pains in the gastric region which, however, are 
not due to the stomach. 

Among the organic affections of the stomach which give rise 
to gastralgia, and may occasionally be confounded with idio 
pathic gastralgia, are: (a) Chronic gastric catarrh; (b) cancer of 
the stomach; (c) ulcer of the stomach; (d) stenosis of the pylorus. 

In chronic gastric catarrh the pains are very seldom intense, 
they have a more continuous character, and do not appear in 
paroxysms. 

In cancer of the stomach the pains may be intense at times, 
but they are also, as a rule, more steady, never leaving any 
perfectly free intervals, while in idiopathic gastralgia the pains 
appear in the form of attacks lasting only several hours and 
alternating with complete euphoria. 

Ulcer of the stomach occasionally presents much more simi- 
larity to the affection under consideration. The characteris- 
tic signs of ulcer (a circumscribed spot in the gastric region or 
to the left of the eleventh to twelfth dorsal vertebra, very pain- 
ful on pressure, the aggravation of the pains after the ingestion 
of food, especially of coarse substances, a preceding hemor- 
rhage) will, if present, make the differential diagnosis between 
this affection and idiopathic gastralgia very easy. Sometimes, 
however, all of the characteristic symptoms mentioned are ab- 
sent, and then it becomes very difficult to distinguish between 
these two affections, for there undoubtedly exist ulcers of the 
stomach which give rise to more or less periodic paroxysms. 

1 Renvers: Berl. klin. Wochenschr., 1888, No. 53. 



GASTRALGIA. 447 

In these doubtful cases it is advisable to institute the Ziemssen- 
Leube rest treatment of ulcer, and if this proves beneficial it 
will speak in favor of the affection having been an ulcer; the 
failure of tins treatment would rather tend to indicate that the 
affection is nervous gastralgia. 

Stenosis of the pylorus is accompanied with typical attacks 
of gastralgia. When frequent vomiting and ischochymia are 
present, the differential diagnosis is not difficult. If, how- 
ever, the two symptoms mentioned are absent, it may some- 
times become quite difficult to decide between the two con- 
ditions. 

In diagnosticating nervous gastralgia, it will be still more 
important to differentiate between some functional disorders 
of the stomach which may be associated with pains. Such 
affections are: (a) Hyperchlorhydria; (b) periodic and chronic 
continuous hypersecretion; (c) achylia gastrica. In hyper- 
chlorhydria and hypersecretion the pains, as a rule, disappear 
after the ingestion of food, and even a severe attack may be 
checked by the taking of some food. In achylia gastrica the 
pains exist only while there is food in the stomach, but not in 
its empty condition, while in nervous gastralgia the pains ap- 
pear independently whether there be food in the stomach or 
not. Besides these clinical symptoms in all of the functional 
disorders just mentioned, the exact diagnosis can be made by 
the results of the examination of the gastric contents. 

There are other conditions which also provoke pains in the 
gastric region, which are not due to the stomach. 

Muscular pains of the abdomen, due either to rheumatism 
or to overexertion, may give rise to mistakes in diagnosis. 
The pain in these affections, however, does not appear par- 
oxysmally and disappears if due to overexertion when the 
patient assumes a recumbent position and the abdomen is 
relaxed. 

Neuralgia of the lower intercostal nerves is characterized by 



448 DISEASES OF THE STOMACH. 

extreme sensitiveness on pressure in a certain intercostal space, 
extending forward from the vertebral column; the pain is more 
superficial than in gastralgia. 

Gall stones frequently give rise to attacks of intense pains 
which may be mistaken for gastralgia. Whenever there is a 
distinct history of cholelithiasis (a preceding icterus, the ap- 
pearance of gall stones in the stools, swelling of the liver) the 
diagnosis is easy. When, however, these characteristic symp- 
toms are absent, then it becomes more difficult to differentiate 
between gastralgia and biliary colic. The following points will 
help to establish the differential diagnosis. In gall stones the 
attack of pain is frequently associated with a rise of tempera- 
ture. The pains are also felt more intensely to the right of the 
abdominal cavity (liver). In gastralgia there is, as a rule, no 
fever and the pains on the right side are not so well marked as 
in biliary colic. In many instances the diagnosis between gas- 
tralgia and biliary colic will remain doubtful, and it is then 
advisable to institute a treatment which would be suitable for 
gall stones. The success or the failure of the treatment will 
aid in the establishment of the correct diagnosis. 

Enteralgia or intestinal colic is characterized by the change 
of the site of the pains from one place to another in the ab- 
dominal cavity, while in gastralgia the pain is fixed at one and 
the same area. Another point in the differential diagnosis be- 
tween these two conditions is the circumstance that in enter- 
algia the pain is either relieved or disappears entirely after the 
passage of flatus. Furthermore, enteralgia is very often the 
result of irregularities of the bowels, and the condition is there- 
fore ameliorated after these have been regulated. 

Renal calculi may also give rise to colicky pains. These are 
characterized, however, by radiation along the ureter to the 
bladder. The passage of a small stone or of gravel of or blood 
clots with the urine will easily establish the true nature of the 
condition. 



GASTRALGIA. 449 

Treatment. — In treating a case of gastralgia it is of the ut- 
most importance to recognize the primary cause of this condi- 
tion. Thus in gastralgia of malarial origin quinine in large 
doses will be the best remedy, while in that due to chronic 
nicotine poisoning a cure will be obtained by forbidding the 
patient to smoke. Gastralgia resulting from chlorosis will have 
to be treated by the administration of iron, arsenic, bone mar- 
row, and other blood-producing substances. Gastralgia due to 
hysteria and neurasthenia should be treated by hydropathic 
methods, massage, and large doses of bromides. Primary gas- 
tralgia, or gastralgia in which no etiological factors can be 
found, is best treated by the application of the galvanic cur- 
rent, either percutaneously or by the intraventricular method. 
The latter mode of treatment I consider much superior. I 
would emphasize that methodical application of the galvanic 
current intra ventricularly, administered for a period of from 
four to six weeks, rarely fails to relieve the most intense and 
obstinate cases of idiopathic gastralgia. 

All the methods of treatment just mentioned have in view 
the prevention of the attacks. The gastric attacks as such, 
however, should be treated in the following manner. Pains in 
the abdomen not very intense in character are frequently re- 
lieved by the application of a hot-water bag or a warm linseed 
poultice, or by the assumption of a recumbent position, and 
the taking of warm drinks. Hoffman's anodyne (ten to 
twenty drops) in sugar water or on a lump of sugar, or tinc- 
ture of valerian (fifteen to twenty drops) may also relieve the 
pain. If the attacks of gastralgia, how T ever, appear in intense 
form, the administration of an opiate can seldom be avoided. 
The best and quickest way to relieve the suffering is a hypo- 
dermic injection of morphine (one-sixth to one-fourth of a 
grain); suppositories of either codeine or opium in combina- 
tion with belladonna are very useful. I frequently prescribe 
suppositories of two-thirds of a grain of opium and one-sixth 

29 



450 DISEASES OF THE STOMACH. 

of a grain of belladonna extract, to be taken every two or 
three hours until the pains cease. 

Gastralgokenosis (Boas). 

Under the name of gastralgokenosis Boas 1 described a con- 
dition in which there is present pain in the stomach when it 
becomes empty. Partaking, of food very soon allays the pain. 
This condition may appear periodically or permanently. It 
belongs to the sensory neuroses of the stomach. Besides the 
nerve sedatives, frequent meals are here indicated. 

Motor Neuroses. 

Physiologically as soon as food has been swallowed and has 
passed the pharynx, the further motion of the bolus is accom- 
plished without our consciousness. We know from experience 
that the peristaltic action of the oesophagus carries the bolus 
to the cardia, which has opened during deglutition, and through 
it to the stomach. The cardia apparently remains closed, if 
not all the time, then at least when the stomach is at work. 
The pylorus is also closed during the act of gastric digestion, 
and opens at certain intervals, in order to allow portions of 
chyme to pass. The cardia and pylorus being closed, the ana- 
kinesic work of the stomach can go on without difficulty. If 
one of the arrangements just mentioned is disturbed, then 
pathological conditions arise. They may consist either in an 
exaggerated action or in a marked diminution of the work of 
one of the above functions. 

Spasm of the Cardia (Cardiospasmus) . 

Cardiospasmus represents a condition in which there is a 
spasmodic contraction of the cardia and the lower part of the 
oesophagus, causing pain and dysphagia, and not dependent 
upon an anatomical lesion. 

1 J. Boas: "Krankh. des Magens," II, Teil, 4te Auflage, S. 260, Leipzig, 
1901. 



SPASM OF THE CARDIA. 451 

Symptomatology. — Although chewing and swallowing food is 
accomplished without difficulty, as soon as a few mouthfuls 
have been ingested a feeling of pressure is experienced in the 
region of the upper and middle portions of the sternum. The 
patient feels as if something had remained in the oesophagus. 
At the same time he has also a slight sensation of d} T spncea. 
Instinctively the inspirations now become much deeper and the 
expirations are performed with much force. The latter act 
frequently causes a regurgitation of the oesophageal contents. 
As soon as the oesophagus has become empty in this way the 
patient feels better and the symptoms just described disap- 
pear. The same phenomena come into play as often as the 
patient begins to eat. 

Cardiospasms may appear in an acute form and last only a 
very short time (one to two days), or it may, in rare instances, 
exist as a chronic affection and last for many years. In the 
latter instance it must always be considered as a grave trouble. 
The chronic form, although originally based on the same de- 
rangements, manifests itself in a somewhat different way from 
the acute variety. The same difficulties (dysphagia) are ex- 
perienced as described above after the swallowing of food. In- 
stead of regurgitating the food, however, the patient instinc- 
tively learns to force it down into the stomach, taking a very 
deep inspiration and compressing the thorax by muscular 
action while holding his breath. Liquid and semiliquid foods 
are easily forced down into the stomach in the manner just 
described. Most of the patients learn to ingest even coarse 
substances; they are obliged, however, to take a few mouth- 
fuls of liquid before they can pass the food into the stomach. 
As a rule, in all these cases of chronic cardiospasmus the 
oesophagus becomes dilated, and can easily hold from 300 to 
400 c.c. That is the reason why patients afflicted with this 
trouble perform the act of forcing the food further down, not 
after every one or two mouthfuls, but rather after having 



452 DISEASES OF THE STOMACH. 

already taken quite a considerable quantity, as the food mean- 
while can easily lodge within the oesophagus. As a rule, three 
or four intermissions are made by the patient during a meal in 
order to force the food into the stomach. 

In some cases the dysphagia is more pronounced on certain 
days, and less on others. Such patients are occasionally able 
to take an ordinary meal without the slightest difficulty. As a 
rule, however, these good days are not numerous. The expla- 
nation for this variable condition lies in the assumption that 
the spasmodic contraction of the cardia alternates with periods 
of relaxation. These periods of relaxation, however, are found 
only in cases which are not of long standing. If the condition 
has lasted for a considerable length of time (one to two years), 
a dilatation of the (Esophagus is often the result. As soon as 
this has occurred, the dysphagia becomes permanent, no mat- 
ter whether the cardia be spasmodically contracted or not. 
The same condition — viz., dilatation of the oesophagus — can 
also be produced, either by paralysis of the oesophagus or by a 
lack of reflex relaxation of the cardia (or paralysis of the ner- 
vus dilatator cardia?, Oppenchowski). After dilatation of the 
oesophagus has been established it is generally most difficult 
to decide whether this is a result of a spasmodic contraction of 
the cardia or of one of the two conditions just mentioned. 
The following case 1 well illustrates the latter possibility: 

J. W , 45 years of age, janitor, had typhoid fever twenty- 
five years ago, since which time he has enjoyed perfect health. 

1 Max Einhorn : " A Case of Dysphagia with Dilatation of the (Esopha- 
gus," Medical Record, 1888. Similar cases have been described by S. J. 
Meltzer: Berl. klin. Wochenschr., 1888, No. 8, and J. Maybaum: Archiv 
fur Verdauungskrankheiten, Bd. i., Heft 4. See also Max Einhorn: "Idio- 
pathic Dilatation of the (Esophagus." American Journal of the Medical 
Sciences, September, 1900. Max Einhorn: "Report of a Case of Idio- 
pathic Dilatation of the (Esophagus." N. Y. Medical Journal, May 29th, 
1909. Max Einhorn: " Stretching of the Cardia in the Treatment of Cardio- 
spasm and Idiopathic Dilatation of the (Esophagus." American Journal of 
the Medical Sciences, October, 1910. 



SPASM OF THE CARDIA. 453 

In the beginning of March, 1888, the patient fell down in the 
street, striking his back against a small projection. He rose 
unaided, and resumed his work without any annoyance. On 
the following day he had pains in the upper part of his body, 
especially in his arms; these lasted but a few days and disap- 
peared. 

About fourteen days later the patient began to have a feeling of 
fulness after eating, and had a pressing sensation about the gas- 
tric region. Two or three weeks later he noticed some difficulty 
in taking his food, and tried to assist it by drinking warm water 
several times during the meal; only in this way did he succeed in 
enjoying a whole meal. 

In May, on account of this pressing sensation, the patient was 
compelled to leave the table in the middle of a meal and walk up 
and down the room, making deep inspirations and expirations; 
he used to press with his hands upon the front of the lower part 
of his thorax after having made a deep inspiration and closed the 
glottis. The patient said that these attacks during a meal 
resembled very much a suffocating condition. The described 
manipulation usually brought him relief, allowing him to eat 
again, but then the process repeated itself. In the morning he 
could eat more easily than at noon-time. 

Since June, 1888, the patient has been sleeping very badly 
(at most three hours during the night). When in bed he had 
often a sensation as if something would go up and down in the 
interior of his chest, and when this sensation came on he was 
forced to cough quite often. From time to time it happened 
that he awoke, his mouth being full of fluid; also while awake 
some fluid at times came up into his throat and mouth, this only 
happening when in the recumbent position. "When standing, 
he was never compelled to empty his throat. 

The patient became thin, felt weak and miserable, and soon 
could partake only of fluid. The sight of solid food enraged him 
to such a degree that he threw it away with disgust. Even fluid 
substances were taken only with great difficulty; he used to 
throw his arms backward, and, standing erect, his head leaning 
toward the back, after a deep inspiration and with closed glottis 
he would press firmly. The condition of the patient became 
worse and worse; he lost forty-one pounds during these few 



i:>i DISEASES OF THE STOMACH. 

months, and went for aid to the German Dispensary on October 
23d, 1888. 

Present Condition. — October 23d, 1888: Patient tall in stature 
and lean; looks pale. The integument can be lifted in large folds. 
The physical examination of the thorax and the abdomen cannot 
detect anything abnormal. The heart sounds are normal. Pulse, 
70; respiration, 20; temperature, judging from sensation upon the 
chest, not increased. The patellar reflex is present, and the 
patient is able to stand with eyes closed. The urine does not 
contain any sugar or albumin. The patient complains of not 
being able to eat any solid food, and of difficulty in taking even 
fluids, as he cannot get them down. Besides this, he has nearly 
always a pressing sensation around the chest, coughs very much, 
and is not able to sleep well. 

Examination of the Stomach and (Esophagus. — 1. October 
25th, 1888, at 8 a.m.: Patient drank coffee one hour before. As 
soon as a part of the stomach tube was pushed into the oesoph- 
agus a coffee-brown liquid was ejected, in which there were 
some remnants of food and many epithelial cells present. The 
patient then drank 100 c.c. water. I did not hear any swallow- 
ing sound at the ensiform process during the time that the patient 
drank. On introducing a part of the tube into the oesophagus, 
water of a neutral reaction came out. Thereupon the tube was 
pushed farther into the stomach without any resistance, and the 
patient ejected from his stomach through the tube about 70 c.c. 
of a coffee-brown liquid. Reaction acid, hydrochloric acid 
present (phloroglucin-vanillin test), the degree of acidity 
being 40. 

2. November 5th, at 9 a.m.: On account of loss of appetite, 
the patient had not eaten anything since 2 p.m. of the previous 
day. The tube was introduced for a length of 46 cm. from the 
teeth; a pulpy mass (150 c.c.) came out, in which were present 
small particles of bread; reaction acid, lactic acid present, no 
hydrochloric acid; acidity =4. The patient drank 100 c.c. 
water, the tube was introduced 45 cm., the water came out some- 
what turbid by the admixture of mucus and food remnants; 
microscopically there were many epithelial cells and micrococci. 
After the water had come out, the tube, without being taken out, 
was pushed farther and with but a slight resistance it passed 
into the stomach; the patient was told to empty his stomach, 



SPASM OF THE CARDIA. 455 

but only a few drops of clear fluid were obtained. This 
proved that the stomach was empty. 

3. November 8th: The patient partook of breakfast, and 
then drank water; he was examined an hour later. The tube 
was introduced for a distance of 36 cm., when there appeared a 
fluid containing no hydrochloric acid; thereupon the tube was 
pushed, without any further resistance, into the stomach, and by 
expression a fine chyme was obtained containing hydrochloric 
acid and peptone. 

4. November 13th: The patient took eggs, coffee, and a little 
softened white bread; then he administered his method of bring- 
ing the food down into the stomach by means of pressing (bring- 
ing the muscles of expiration into play, after having made a deep 
inspiration, with closed glottis). An hour later, shortly before 
the examination, the patient was told to press several times 
again. The tube was introduced to a distance of 48 cm., and 
during expiration only 8 c.c. of a turbid liquid were obtained; 
there were present very minute pieces of bread and many epithe- 
lial cells, but no hydrochloric acid; thereupon the tube was 
pushed, without any resistance, into the stomach; now there came 
out a chymous fluid with hydrochloric acid. The patient drank 
200 c.c. water; the tube was introduced about 40 cm., and the 
water came out with a gush. 

5. November 16th: Patient took breakfast at home and ad- 
ministered his method of forcing down his food. The oesopha- 
gus was examined an hour later and found empty. The pharyn- 
geal vault was tickled with the finger to induce vomiting, but 
without success. Thereupon the tube was introduced into the 
stomach, and a fine chymous fluid, containing hydrochloric acid, 
was obtained. The stomach was then filled with air by means of a 
tube and bulb; the air did not escape along the outside wall of the 
tube. By keeping the tube open the stomach was emptied of the 
air; afterwards the lower part of the oesophagus was blown up. 
A considerable quantity of air could be blown into it without 
returning, but upon increasing it still more the air began to 
escape upward through the upper part of the oesophagus, along 
the outer side of the tube wall. During the inflation of the 
oesophagus there was observed, at both sides of the vertebrae 
below the inferior margin of the scapula 1 , somewhat more 
tympanitic resonance, but that was not very decided. 



456 DISEASES OF THE STOMACH. 

It is evident, from the history of this patient, that the diffi- 
culty in bringing the food into the stomach slowly developed a 
few days after the fall, and finally led to complete dysphagia. 
The examinations showed that the contents of the stomach were 
normal. The examinations with the stomach tube show, firstly, 
that the passage through the oesophagus to the stomach is perfectly 
free, for the thick tube passed into the stomach without any 
resistance; secondly, that the oesophagus, in its lower third, must 
be saccularly dilated, as the distance from the teeth to the cardia 
(measured with the tube) is 48 cm.; whereas in the case of this 
patient, even taking into consideration his large frame, it ought 
normally to be not more than 40 to 41 cm. In this cavity the 
tube, leaning on the wall of the oesophagus, was compelled to 
assume with its lower end the form of a semicircle, and thus pro- 
duce this high figure. That the patient is really unable, in 
swallowing, to bring even liquids down to his stomach, except 
by the pressing action, is proven by the fact that swallowed water 
could always be taken out from the oesophagus by means of the 
tube, w T hereas immediately afterward the tube, pushed into the 
stomach, brought up part of the stomach contents containing 
hydrochloric acid. 

Ewald mentions a similar case, in which the tube passed into 
the stomach without encountering any resistance at the cardia 
while the food still remained within the oesophagus. He con- 
siders this case as one of spasmodic contraction of the cardia 
and believes that although no resistance was felt with the tube, 
still the cardia became contracted during deglutition. I do 
not think it is necessary to assume that the cardia acts differ- 
ently during insertion of the tube than while taking food. As 
I remarked above, the symptom of dysphagia exists as soon as 
dilatation of the oesophagus has been established, no matter 
whether the cardia be contracted or not, for the dilated oesoph- 
agus cannot contract sufficiently to carry the food into the 
stomach. In order to accomplish this, other means will be 
necessary, consisting, as mentioned above, in the compression 
of the thorax, after a deep inspiration. 



SPASM OF THE CARDIA. 457 

Diagnosis. — The diagnosis of the acute form of cardiospasms 
is based upon the following points: The existence of dysphagia 
for a short time, the absence or retardation of the swallowing 
sounds, and the resistance encountered at the cardia on inser- 
tion of a tube into the oesophagus — a resistance, however, 
which can be overcome. It is characteristic of this spasmodic 
contraction of the cardia that the resistance felt during the 
introduction of different-sized bougies is the same or rather 
less for those of large calibre, while in organic strictures of the 
cardia a thick tube is unable to pass and the thin ones en- 
counter either no resistance at all or glide through with some 
resistance. The diagnosis of the chronic forms of cardiospas- 
mus can be made if the symptom of dysphagia has lasted for 
long periods of time (three months to two years) and the ex- 
amination with a bougie reveals the same condition as described 
in the acute form. 

Dilatation of the oesophagus ("idiopathic" or "spindle-shaped 
dilatation of the oesophagus"), which is of so frequent occur- 
rence in this affection, and its most important sequelae can be 
diagnosed in the following way: The patient one to two hours 
after a meal is examined by means of a tube, which is intro- 
duced into the oesophagus, and if there be some contents (in 
the oesophagus) they are withdrawn. The patient now drinks 
a glassful of water (200 to 300 c.c.) and is told not to perform 
the forcing motions. After an interval of about five minutes 
the tube is again inserted into the oesophagus. If dilatation 
of the latter exists, the water will now appear through the 
tube in about the same condition as when drank, i.e., not 
mixed with food. On pushing the tube farther down through 
the cardia into the stomach, real gastric contents will now ap- 
pear, showing that the water the patient drank had remained 
all the time within the oesophagus and had not mixed with 
the food. Absence of the swallowing sound and an X-ray 
photograph of the oesophagus also help to recognize this affec- 



458 DISEASES OF THE STOMACH. 

tion. In making the diagnosis of idiopathic dilatation of the 
oesophagus, diverticula must first be excluded. The latter 
occur in the upper portion of the oesophagus, just beneath the 
cricoid cartilage. A bougie meets with a resistance at the bot- 
tom of the sac. Occasionally a thick bougie will be able to 
pass into the stomach, especially when the diverticulum is 
empty and it by chance did not enter into the lumen of the 
diverticulum. The diverticula usually lie on the left side of the 
oesophagus, and there is occasionally a visible protrusion of the 
neck. Pressure on it is apt to produce a gurgling sound. 

Prognosis. — The prognosis of the acute form is good. That 
of the chronic form is good quoad vitam and somewhat more 
grave quoad valetudinem completam. 

Treatment. — The acute form is best treated by large doses 
of bromides and by the introduction of large-sized sounds. 
Opiates and chloral hydrate have also sometimes a beneficial 
effect. In the chronic form, the treatment will consist in the 
following: 1. The patient is allowed to take only fluid or semi- 
fluid foods; 2. After every meal he must perform his pressing 
action for a long time; 3. Every evening, before going to bed, 
the oesophagus is emptied and washed by means of the tube; 
4. The patient introduces the tube into his stomach once every 
day, in order to relax the cardia. After a while, when the 
patient feels better, he can begin to introduce greater variety 
into his diet, and is allowed to eat even solid substances. 

In case even liquids cannot be managed by the patient, the 
introduction of the oesophageal drainage tube 1 after each meal 
will be of benefit. 

The drainage tube is constructed in the following manner: 
A soft rubber tube 30 mm. in diameter and 21 inches in length 
is provided with a large number of apertures from the lowest 
part to seven inches above it. There are two marks at 17 and 

1 Max Einhorn: "A Suggestion as to the Dietetic Treatment in Dilata- 
tion of the (Esophagus." Medical Record, July 4th, 1908. 



SPASM OF THE CARDIA. 



459 



21 inches from the end, and the entire tube is 
provided with a mandrill (Fig. 106). 

The drainage tube with mandrill is intro- 
duced by patient himself immediately after 
taking fluid or semi-fluid food. The mandrill 
is then removed and the tube is moved up and 
down for about half to one minute between 
the marks at 17 and 21 inches, and is then 
withdrawn. Moving the tube to and fro has- 
tens this process as it tends to eliminate the 
closure at the cardia. 

The principle on which the drainage tube 
works is as follows : If from the dilated oesoph- 
agus fluids do not get into the stomach, the 
failure may be caused by one of two things: 
(1) Lack of peristalsis of the oesophageal mus- 
cles: (2) hermetic closure at the upper or lower 
part of the oesophagus. The closure need not 
be — and usually is not — of an organic nature, 
and bougies or sounds do not find any difficulty 
in passing the entire canal. The walls of the 
oesophagus may, however,' lie in such close ap- 
position or may be folded in such a manner 
either at the beginning or at the cardiac end 
that it is absolutely air tight. This prevents 
fluid from escaping from the oesophagus, just 
as from a pipette nothing can drop if we close 
the upper end with the thumb. To facilitate 
the drainage of the oesophagus into the stomach, 
all hermetic closure of the oesophagus must 
be overcome and a continuous canal between 
the two organs must be established. 

That the drainage tube really works as de- 
scribed, is proved by the following: 



o 



Fig. 106. — The 
(Esophageal Drain- 
age Tube with 
Stiletto. (Einhorn.) 



460 DISEASES OF THE STOMACH. 

1. After drinking a glass of water or milk patient feels a 
pressure in the thorax; if the drainage tube is introduced and 
left for about half a minute, the feeling immediately disappears. 

2. After taking about 250 c.c. of fluid, the entire amount 
may usually be recovered after introducing the usual stomach 
tube (to about 15 inches from the teeth). If, however, after 
drinking the water, the drainage tube is introduced and left 
in the stomach for about one-half a minute, we can no longer 
obtain any fluid in the usual manner. 

3. The patient drinks a glass of milk in which one ounce of 
subnitrate of bismuth has been suspended and is exposed to 
the X-ray; fluoroscope shows a shadow along the sternum (as 
in the photograph). Now the drainage tube is introduced and 
the fluoroscope shows that the shadow has disappeared. 

All this shows that the drainage tube transmits oesophageal 
contents promptly into the stomach. 

Recently forcible stretching of the cardia has been performed 
successfully, first after an operation (opening the stomach and 
reaching the cardia) and latterly by special instruments with- 
out any surgical intervention. The latter procedure has been 
practised by Rosenheim, 1 Sippey, 2 Plummer, 3 Gottstein, 4 and 
myself. 5 Plummer's report is particularly of great import. He 
has treated forty cases of cardiospasm by forcible dilatation of 
the cardia, and says: "The immediate results are most strik- 
ing. The patients are almost invariably able to take any kind 
of food at the following meal. There is often a complaint of 

1 Theodore Rosenheim: "Beitrage zur Erkenntnis der Divertike und 
Ektasieen der Speiserdhre." Zeitschrift fur klinische Medizin, xli, 1902. 

2 Sippey: Quoted by Plummer. 

3 Plummer: "Cardiospasm, with a Report of Forty Cases." Journal of 
the American Medical Association, August 15, 1908, p. 549. 

4 George Gottstein : " Weitere Fortschrif te in der Therapie des chronis- 
chen Cardiospasms. " Archiv fur klinische Chirurgie, lxxxvii, 3, p. 497. 

5 Max Einhorn: " Report of a Case of Idiopathic Dilatation of the (Esoph- 
agus with Cure and Description of a New Cardiodilator." N. Y. Med. 
Journal, May 29th, 1909. 



SPASM OF THE CARDIA. 



461 



soreness for the first twenty-four hours. The gain in 
and strength is rapid. In twenty-nine cases there was 
currence." All the clinicians used a dilator ^ 
consisting of a rubber tube with an inflat- 
able air balloon at its end. "With this dilator 
various cures have been observed. Gottstein 
covered the rubber balloon with silk, and 
published only lately six cases of cardiospasm 
with good results. 

A metal dilator would certainly be prefer- 
able to the inflatable dilators, since it would 
be easier to handle and would work quicker. 
Therefore I undertook to construct such an 
instrument. The instrument consists mainly 
of a metal spiral covered with a rubber tube 
and is divided into the following parts (see 
Fig. 107): a. An expanding end; b. flexible 
shaft; c. pilot wheel; d. handle and casing for 
actuating mechanism; e. flexible spiral shaft 
enclosing transmission wire;/, scale; aa. ex- r 
panding end when giving maximum dilata- 
tion. 

Before using, the dilator is covered with a 
rubber bag which is fastened with silk and 
tested as to its perfect working. The instru- 
ment after immersion in warm water is intro- 
duced into the patient in the sitting position, 
pushed through the cardia so that only one 
centimetre projects beyond it. The distance 
of the cardia from the lips is determined by ^ 
a larger bougie (about from 40 to 50 mm.), 

Fig. 107. — The Cardiodilator. a, expanding end; b, flexible (rj- 
shaft: c, pilot wheel: 'I, handle and casing for actuating mechan- 
ism: <?, flexible spiral shaft enclosing transmission wire; f, Bcale; 
aa, expanding end when giving maximum dilatation. 



weight 
no re- 



4(>2 DISEASES OF THE STOMACH. 

by determining the point at which resistance at the cardia can 
be found. The distance of this point from the lips, which can 
easily be measured on the whale- bone bougie shows the loca- 
tion of the cardia. Now the pilot wheel, c, is turned to the 
right, until the patient complains of pain; when this point has 
been reached we must stop the dilatation. The instrument is 
left from one to two minutes, then the wheel is turned back 
entirely to the left, and the instrument is withdrawn. 

In a few days the dilator can be opened to the maximum 
width without causing the patient pain. The patient feels only 
a sensation of distention in the cardia. It is well to do this 
once weekly for several months. The dilator is made in two 
sizes, whose maximum circumference is 8 and 10 cm., respect- 
ively. 

Of the cases treated by forcible stretching I shall describe 
one. 

May 10, 1902. Idiopathic Dilatation of the (Esophagus. 

Clifford V., aged twenty-six years, suffered for two years 
from pains in his chest and eructation of food. In 1901 he 
had typhoid fever, which reduced him still more. In 1902 he 
weighed 125 pounds, felt weak, complained of cramps in his 
chest, and vomited frequently. 

Examination of the chest and abdomen revealed nothing ab- 
normal. In the fasting condition the swallowing sound was 
not present. A sound introduced into the oesophagus brought 
up 140 c.c. of fluid with food remnants, of acid reaction, no 
HC1. The tube was pushed farther into the stomach and a 
few cubic centimetres of fluid mixed with HC1 was evacuated. 
If the patient drank a glassful of water, the entire quantity 
mixed with a little mucus could be obtained from the oesopha- 
gus after five minutes. 

The diagnosis of idiopathic dilatation of the oesophagus was 
made and the usual treatment followed. The patient gained 
in weight, and felt better, but the difficulty of eating remained. 



SPASM OF THE CARDIA. 



463 



In 1904 I constructed a special instrument for this patient 
in order to dilate the cardia. The stiff part, however, was too 
long, and its introduction did not succeed. Thus, the patient 
lived on, never able to enjoy a meal like others, always having 
to interrupt his meal in order to force the food down by cer- 
tain manipulations. 

On April 14, 1909, the patient was again examined. A con- 
dition similar to that described was found. The swallowing 




B. — Radiogram of C. V.'s (Esophagus after taking Bismuth and Cream. 
January 29, 1907. 



sound was absent. The tube introduced into the oesophagus 
(15 inches) brought up 200 to 300 c.c. of fluid containing food 
(reaction neutral or faintly acid; HC1 = 0; ferments absent). 
On pushing the sound farther down (21 inches), stomach con- 
with presence of iv^o HC1, appeared. At that time the 
patient weighed 137 pounds stripped. On April 20 I began 



464 



DISEASES OF THE STOMACH. 



to dilate the cardia, at first up to 7 cm., later to 8 cm., then 9 
cm., and finally 10 cm. Immediately after the first or second 
week of this treatment the patient could eat more easily and 
he soon was able to eat larger meals in the company of his 
friends without having to interrupt his meals. He steadily 
gained in weight, and in December weighed 177 1/2 pounds, 
stripped. He had gained in seven months of treatment 40 1/2 
pounds in weight. The swallowing sound could then fre- 




Fig. 109. 



-Radiogram of G. V.'s (Esophagus after taking Bismuth and Cream. 
January 14, 1910. 



quently be heard six to seven seconds after the drinking of 
water. Occasionally the oesophagus was entirely empty. 
After drinking 200 c.c. of water I could obtain after one minute 
only 50 c.c. from the oesophagus. 

Particularly instructive are the X-ray pictures of the oesoph- 
agus. Fig. 108 is a radiogram of the oesophagus on January 



SPASM OF THE CARDIA. 



465 



29. 1907. before the treatment of stretching began, and Fig. 109 
is that of January 14, 1910, about eight months after this treat- 
ment was instituted. It is evident that the transverse diam- 
eter of the oesophagus has become markedly smaller. Fig. 110 
shows the oesophagus in the lateral position after partaking 
of thick bismuth mush. The peristalsis of the oesophagus can 
be seen. The patient then drank a glassful of milk, and an- 
other picture was taken in the same position immediately after- 




Fig. 110. — Radiogram of C. V.'s CEsophagus after Bismuth in the Lateral Positi 

January 14, 1910. 



ward. The oesophagus had emptied itself completely (Fig. 111). 
I had a considerable number of cases of cardiospasm and 
idiopathic dilatation of the oesophagus, which by means of 
forced stretching of the cardia were either entirely cured or so 
much improved that they may be considered almost cured. 
For even if a small residue is found in the oesophagus in some 
30 



466 DISEASES OF THE STOMACH. 

of these patients, still they do not experience any discomfort 
at meals and can partake of them in the same manner as nor- 
mal persons. Case (C. V.) deserves special mention, because 
the X-ray photographs before and after treatment by means 
of stretching show plainly the variation in size of the oesophagus, 
which is only one-third as large as before treatment. The suc- 




Fig. 111. — The Same as Fig. 110, after Drinking a Glassful of Milk a Few Minutes 
after the Bismuth, Lateral Position. January 14, 1910. 

cess of treatment by means of stretching is very marked, and 
may now be regarded as the accepted mode of treatment in 
this disorder. 

Eructation. 

The frequent expulsion of gas from the stomach through the 
mouth is known as eructation or belching. While this condi- 
tion may accompany the most varied affections of the stomach, 



ERUCTATION. 467 

it may also occur alone and is then considered as a neurosis. 
It is characteristic of the latter that the gas expelled has no 
particular odor and consists principally of air. The eructa- 
tions of gas may appear in the form of attacks lasting half an 
hour to an hour or much longer. The intervals between the 
eructations during an attack are sometimes very short, so that 
there may occur two or three belching spells in one minute. 
Sometimes the expelled gas does not come from the stomach, 
but merely from the oesophagus, and consists of air which has 
just been swallowed previous to the belching. Some people 
are able to produce tins kind of belching voluntarilj\ Ewald 
states that he can belch at will from the oesophagus. By 
auscultating himself to the ensiform process, he became convinced 
that the ah' voluntarily eructated did not come from his stom- 
ach, as no sound whatever was audible at the ensiform pro- 
cess. In view of tins fact and of the importance of swallowing 
of air in the production of belching, Bouveret 1 proposed to 
designate this condition as aerophagia (eating of air). I am 
inclined to think that the frequent eructations from the 
oesophagus, winch are always preceded by acts of deglutition and 
accompanied by loud sounds, are identical with singultus, and 
result from a condition of irritation of the phrenic nerves. 
Attacks of singultus of short duration (ten to fifteen minutes) 
are of frequent occurrence, while attacks lasting several days 
without interruption are quite rare. The latter occur either 
accompanying very grave conditions (cancer of the stomach 
and some cases of peritonitis) or again as a primary neurosis. 
Nervous belching may either last several days or exist for 
years. The patients are never disturbed by the act of belch- 
ing during sleep, but in the daytime the trouble may sometimes 
be so annoying as to keep them away from society or even 
from business. The act of belching is ascribed by some to an 
increased peristaltic action of the stomach, by some to a de- 

1 Bouvorft : I. c, p. 611. 



4GS DISEASES OF THE STOMACH. 

criviscd contraction or a relaxation of the cardia, and by some 
to both of these conditions together. 

Etiology. — Nervous belching is frequently found in hysterical 
and neurasthenic persons, but also in people not otherwise 
showing any neurotic symptoms whatever. It sometimes ap- 
pears after great mental worry or excitement, or also as a 
sequel of an acute gastric catarrh. 

Treatment. — In persons with a weakened constitution, in 
neurasthenics and hysterical persons, this primary trouble must 
be treated as such. If the condition is idiopathic, the admin- 
istration of the bromide salts is very valuable. The faradic 
current applied intraventricularly has given me very good re- 
sults in this class of cases. Diet does not seem to have much 
influence upon the affection. I deem it very important to tell 
the patient to try and suppress the belching as often as he 
can. Very frequently this measure alone suffices to effect a cure. 

Pyrosis. 

By the term pyrosis is designated the ejection of chyme from 
the stomach into the oesophagus. As a rule, a burning sensa- 
tion is then felt at the pit of the stomach, which is also known 
under the name of heartburn. While pyrosis is of frequent oc- 
currence in hyperchlorhydria, it may also appear as a neurosis 
even if the gastric secretion is perfectly normal. It is gener- 
ally believed that the sensation of heartburn can be produced 
solely by acid fluids, but the sensation can exist even without 
the presence of an acid. Thus I have at present under obser- 
vation a patient with achylia gastrica, in whom the gastric 
contents are almost always of a neutral reaction and who never- 
theless frequently complains of heartburn. 

Regurgitation. 

Regurgitation denotes a condition in which either liquids or 
liquids mixed with solid food particles are ejected in small por- 



REGURGITATION. 469 

tions from the stomach into the mouth. These contents are, 
as a rule, spit out; occasionally, however, they are again swal- 
lowed. It is generally believed that a relaxation of the cardia 
is the cause of the trouble. In most instances regurgitation 
takes place involuntarily, in some, however, the patient is able 
to produce it at will. In nervous regurgitation the ejected 
matter does not show any abnormal condition (and does not 
smell or taste bad). This is different if regurgitation is the 
result of an organic affection of the stomach. Regurgitation, 
as a rule, appears soon after meals, and this process may re- 
peat itself quite a number of times in a short period. In most 
instances tins affection does not lead to any serious conditions. 
Sometimes, however, if regurgitation is very obstinate and large 
portions of chyme are constantly ejected, serious complications 
may result from inanition. 

The following case, which I have observed, is interesting with 
regard to this point. 

A boy, 8 years of age, had been suffering, as his mother stated, 
from obstinate vomiting for about three years. The little 
patient looked extremely pale and emaciated. He had cold 
extremities, became dizzy quite frequently, especially on rising, 
and felt very weak, so that a walk of two blocks tired him out. 
On further inquiry the mother stated that the boy did not vomit 
a large quantity at once, but brought up small portions of food 
from the stomach which he spat out. This occurred fifteen to 
twenty or even more times after each meal. Physical examina- 
tion of the chest revealed nothing abnormal. The abdomen was 
slightly bloated; the splashing sound could be produced in the 
gastric region, extending to two fingers' width below the navel. 
On palpation no painful spots could be discovered. The patient 
took a small meal and was observed half an hour afterward. 
Regurgitation took place while he was in my office. The 
ejected chyme revealed on examination the presence of free 
hydrochloric acid in normal amounts. The case was diagnosed as 
nervous regurgitation, and the extreme degree of anaemia and 
malnutrition referred to insufficient nutrition on account of the 



470 DISEASES OF THE STOMACH. 

great amount of chyme which was constantly ejected from the 
stomach and in this way lost to the organism. The little patient 
was given no medicine, but was told never to spit out the food 
which came up into his mouth, but rather to swallow it. The mother 
was told to keep constant watch over the boy, in order to have 
this rule strictly observed. In about three months the patient 
began to grow stronger and gained in weight, so that after this 
time he could hardly be considered sick. Moreover, regurgita- 
tion now appeared quite seldom and was then repeated only 
once or twice. 

Etiology. — Regurgitation may develop either in consequence 
of great mental worry or nervous strain or as a sequel of an 
acute gastric catarrh. 

The prognosis is almost always good. 

Treatment. — This consists in the application of the faradic 
current intraventricularly and in the administration of strych- 
nine. In conjunction with these remedies, the patient must 
be told to suppress regurgitation whenever possible. At first 
he will often fail to do so, but after a while he will be able to 
suppress it, and still later the tendency to regurgitation will 
entirely disappear. In cases in which regurgitation is of fre- 
quent occurrence and obstinate, and nutrition begins to be in- 
sufficient, it is of the greatest importance to forbid the patient 
to spit out the ejected food and to tell him to swallow it again. 
This treatment may occasionally artificially produce the con- 
dition which will now be described. 

Rumination. 1 

Synonyms. — Merycism, "chewing the cud." 

By rumination is designated a condition in which the food 
returns, without nausea, in small portions, from the stomach 
through the oesophagus into the mouth, some time after meals; 
here it is chewed anew and swallowed. 

1 The history and literature of this affection can be found in my paper: 
"Rumination in Man," Medical Record, May 17th, 1890. 



RUMINATION. 471 

Etiology. — If we are not inclined to accept as the cause of 
rumination an anatomical alteration in the upper digestive 
tract — a hypothesis not demonstrated or even rendered prob- 
able — two explanations still present themselves, namely, 
heredity and self-acquisition. But as heredity has been met 
with in only very few cases of rumination, and thus cannot be 
taken for the main cause of the affection, it appears of import- 
ance to lay most stress on self-acquisition. This may arise, 
firstly, from imitation; secondly, from necessity and custom 
(adaptation). 

As the best example of imitation Koerner's 1 case may be 
cited, where a ruminating governess imparted her own affec- 
tion to her two pupils; after the governess had been sent away, 
the two children quickly got rid of their rumination. 

In many cases of rumination the patients first, before the 
beginning of the trouble, had for some time suffered from dys- 
peptic symptoms with regurgitations; thereafter they com- 
menced to swallow what came up by regurgitation, and, finally, 
were aware of ruminating. In these cases the development of 
rumination from slight pathological conditions, by necessity 
and custom, can be plainly seen. 

Most of the reported cases of rumination (in all the litera- 
ture, to date, but one hundred and six cases have been de- 
scribed) are of the male sex, and belong chiefly to the profes- 
sional and more educated classes (physicians, philologists, and 
lawyers); of the female sex only a few cases are reported as 
ruminants (in all nine cases, figured from the paper of Johan- 
n). 2 

This alone would not prove that rumination, in fact, appears 

requently in men of the lower class and in the female sex; 

for very often a man of the working class does not deem his 

condition as a ruminant to be abnormal, and does not make 

1 Koerner: Deutsch. Arch. f. klin. Modicin, Bd. xxxiii., p. 554. 

2 Johannessen: Zeitschr. f. klin. Modicin, Bd. x., p. 274. 



472 DISEASES OF THE STOMACH. 

mention of it to his physician. On the other hand, there are 
several people (especially among women) who would like to 
conceal their affection, and therefore do not speak about it. 
In consequence thereof, the correct relation of rumination, in 
reference to its distribution among the two sexes and the dif- 
ferent social classes, cannot be ascertained from the cases re- 
ported in literature. 

Among the insane and idiots rumination has been found 
quite frequently. Thus G. Cantarono 1 found nine cases of 
rumination among four hundred male insane; but among three 
hundred female insane he found no ruminants. Bourneville 
and Seglas 2 likewise lay stress on the frequency of rumination 
in idiots, and also in epileptics. 

Duration. — The duration of merycism is very variable; some- 
times there is rumination going on uninterruptedly during the 
whole life. Often it appears in the form of attacks, periods of 
rumination alternating with normal periods of varying duration. 

Sometimes rumination suddenly ceases at the occurrence of 
an important change in the life of the merycist. Thus a case 
is on record in which a person ceased to ruminate immediately 
after marriage. But there is also a report of another case in 
which rumination made its appearance a day after marriage. 

These varying circumstances can only prove how deeply 
rumination is connected with the nervous functions. 

Chemical Analysis of the Stomach Contents. — The investiga- 
tions upon the chemical condition of the stomach in mery cists 
have been made only within the most recent period. 

Johannessen says briefly, in his elaborate paper on rumina- 
tion, that at the end of rumination the ejected materials 
showed an acid reaction. Alt, 3 in 1888, was the first to make 

1 G. Cantarono: Neurolog. Centralbl., Bd. iv., 1885. 

2 Bourneville et Seglas: "Du Merycisme." Arch, de Neurologie, Paris,. 
1883. 

3 Alt: Berl. klin. Wochenschr., 1888, Nos. 26 and 27. 



RUMINATION. 473 

exact examinations of the stomach contents in a ruminant. As 
soon as the patient suppressed rumination it was found that the 
stomach contents, obtained three to four hours after a test 
dinner, contained free hydrochloric acid, were rather hyper- 
acid, and showed very retarded amylolytic qualtities. But 
as soon as the patient had practised his rumination as usual, 
the stomach contents were less acid and the amylolysis was 
much better. Alt presumes that the rumination in his patient 
had the purpose of correcting the fault made by a deficient 
salivation of the food and the hyperacidity arising from it. 
"We would seem to have." he says, "in rumination a process 
for correcting the hyperacidity caused by a deficient salivation 
and the bad digestion of amylaceous matters." Acting on this 
theory, Alt treated Iris patient with alkalies, with the result 
that the patient was less inclined to ruminate, and further, 
could suppress the habit much more easily. 

In favor of Alt's theory would be perhaps the case of rumina- 
tion reported by W. A. Hubbard. 1 A farmer, aged thirty -five, 
consulted Dr. Hubbard for, as he expressed it, "the restoration 
of his lost cud." This patient had had the habit of ruminating 
his food since a period beyond his recollection, and had always 
enjoyed perfect health; now, for a month the rumination had 
stopped, and this was immediately followed by dyspeptic 
symptoms. All medicaments proved to be of no use. Should 
we look with Alt upon rumination as a means of correction, it 
would be very easy to understand why the patient had the 
dyspeptic symptoms at the cessation of the rumination, and 
hi> wish and hope that "his habit will return as suddenly as it 
left him." justifiable. 

S m afterward, however, Boas 2 published a case of rumina- 
tion in which the chemical analysis of the stomach contents 
showed the acidity to be markedly diminished. The treatment 

: W. A. Hubbard: Medical Record, July 31st, 1886, p. 122. 
2 Boa*: Beii klin. Wochen.schr, 1888, No. 831. 



474 DISEASES OF THE STOMACH. 

consisted in giving the patient hydrochloric acid, and the result 
was a diminution of the rumination and an amelioration of the 
glandular function of the stomach. In this way by Boas' case 
Alt's theory has been refuted. Shortly afterward Juergensen 1 
published two cases of rumination, with an absence of the free 
hydrochloric acid. 

In considering the figures of the chemical analysis of the 
stomach contents of merycists I have observed, I must say 
that no relationship whatever can be found between the 
chemical condition of the stomach contents and rumination. 
In some of the patients the condition of the stomach was per- 
fectly normal in every respect; the chemical analysis showed the 
presence of hydrochloric acid in a normal quantity; the power 
of motion also proved to be adequate; Ewald's salol reaction 
appeared after one hour; in others the chemical analysis of the 
stomach contents varied greatly on different days. There was 
found once normal acidity (50), once rather s'ubacidity (40), 
and once hyperacidity (100), whereas hydrochloric acid was 
always present. In some, again, there was hyperchlorhydria, 
while in others achylia gastrica prevailed. The conjecture of 
Ewald is therefore confirmed. This author, in his book on the 
"Diseases of the Stomach," says in reference to rumination: 
"I would not be astonished, the conditions being the same, if 
varying degrees of acidity were found in the same patient, 
because such changeable conditions are in the nature of many 

neuroses." One of my patients (K ) furnished the best 

example of such occurrence, and from this we can infer that no 
connection exists between rumination and the chemical condi- 
tion of the stomach. 

During the last nine years I have observed twenty-two cases 
of rumination. One of the first cases, which I described in the 
Medical Record, 2 was as follows: 

Juergensen: Berl. klin. Wochenschr., 1888, No. 46. 

- Max Einhorn: "Rumination in Man," Medical Record, I. c. 



RUMINATION. 475 

March 26th, 1890: G. P , physician, aged 27, had febris 

gastrica in his childhood, and in 1884 typhoid fever. Since his 
ninth year the patient has been troubled with his stomach; at 
that time, during a period of six months, he usually vomited 
after partaking of food, especially of fluid. Sometimes the pa- 
tient had to vomit at the beginning of the meal, immediately 
after the soup, but could nevertheless continue to partake of his 
meal directly afterward. Since then his condition has become 
ameliorated, and instead of vomiting there appeared rumination. 

The rumination in this patient appears spontaneously, about 
one hour after meals, and continues for about a quarter of an 
hour. The food comes up in small quantities (in the form of 
boli). The taste is not sour; in chewing the cud the patient has 
a pleasant sensation. 

"When he partakes of liquid food only (as, for instance, beer, 
bouillon, coffee, milk), there is no rumination. 

In this patient the rumination appears periodically; thus, for 
instance, he ruminated three months, and then was free from 
the trouble for about a year. 

Even during the period of rumination the bowels act regularly; 
the patient, however, often suffers from belching. 

He is able to ruminate at will any time there is food in his 
stomach. The act of rumination proceeds even then without 
any effort. In order to effect the rumination the patient closes 
his glottis and exerts slight pressure over the stomach by means 
of his abdominal muscles; the contents are then ejected in small 
portions into the mouth. Patient is able to do this in any pos- 
ture; when he is sitting or standing, however, it is done with more 
ease than in a recumbent position. In the same way the patient 
is voluntarily able to belch and to vomit; the latter in such a way 
that all the stomach contents are ejected at once. The patient 
is thus enabled to cleanse his stomach easily; he does this by 
drinking a large quantity of water and ejecting it immediately 
after. He also has the faculty of stopping the vomiting at any 
moment he chooses, and in this way he can alternate vomiting 
with rumination. He has diplopia and is color-blind in one eye. 

The father of the patient and several of his brothers and 
sisters are troubled with the stomach; the main symptom of their 
ailment is belching; nobody in the family, however, had rumi- 



470 DISEASES OF THE STOMACH. 

nated. The patient is able to suppress rumination, not feeling 
any pain in doing so. He does not know what causes the period- 
ical attacks of rumination, although he has noticed that after 
any excitement he is more liable to have an attack. 

The physical examination shows no abnormal conditions 
whatever. Patient is of medium height, well developed, some- 
what stout. Tongue perfectly clean. The stomach does not 
seem to be dilated. Seven seconds after swallowing water a 
rattling sound appears on auscultation at the xiphoid process. 

Examinations of the Stomach. — 1. During the rumination 
period, September 15th, 1888. One hour after Ewald's test 
breakfast: HC1 + ; acidity = 50; erythrodextrin + ; achroodex- 
trin + . On the same day the patient took 1.0 gm. salol in a 
gelatin capsule; the urine showed salicyluric acid reaction (it 
became dark red on addition of a few drops of liquor ferri 
sesquichloridi) after one hour. 

2. During an interval of freedom from rumination, March. 
25th, 1890. One hour after test breakfast: HC1 + ; acidity = 54;: 
erythrodextrin + ; achroodextrin + . After this examination the 
patient had an attack of rumination for three days, then it 
ceased. 

Treatment. — Formerly hydrochloric acid, alkalies, narcotics,, 
and bitters were tried empirically now and then, with apparent 
results for a short time, and sometimes without any influence 
whatever. Lately the attempt has been made to remedy the 
error — if any — ascertained after a chemical examination of the 
stomach contents, and hydrochloric acid or alkalies have 
accordingly been given, with good results. 

Koerner tried giving small pieces of ice immediately after 
meals, and warmly recommends this method. Washing out of 
the stomach has been practised by Johannessen, and gavage 
(feeding through the stomach tube) during fourteen days by 
Juergensen, but with only temporary relief. All these remedies 
sometimes effect a temporary amelioration; a permanent cure, 
however, has never been achieved by therapeutic means. As 
an exception to this rule we might perhaps consider the moral 



NERVOUS VOMITING. 477 

treatment — i.e., the patient determines not to ruminate and, 
as soon as a desire to ruminate appears, endeavors to suppress 
it. Ponsgen 1 mentions two cases of meryeism perfectly cured 
by this method. 

This moral treatment can of course be applied more easily 
in cases in which the rumination can be suppressed by the will 
power of the patient, although even in those in which the 
rumination is wholly independent of the will it can also be 
effected. 

In treating Dr. G. P., I made use of this method; he was 
instructed, as soon as he- felt any inclination to ruminate, to 
try with all his powers to suppress it. The patient has carried 
out this rule quite conscientiously, and the meryeism has since 
that time occurred only occasionally. In the treatment of 
several other cases I have applied the same method with the 
best result. 

Nervous Vomiting (Vomitus Nervosns). 

The process of vomiting serves to empty the stomach of its 
contents by the shortest way, that is, through the oesophagus 
and mouth. The mechanism of this action is very complicated 
and a large number of striated and non-striated muscles par- 
ticipate in it. At first the abdominal muscles and the dia- 
phragm contract and compress the abdominal cavity; then 
the stomach contracts and the pylorus closes firmly. At the 
same time the longitudinal fibres of the lower end of the oesoph- 
agus contract and open the cardia; the pressure which is exerted 
by the stomach upon its contents throws them into the open 
oesophagus, which becomes wider and shorter by the contrac- 
tion of its longitudinal fibres. The epiglottis turns upon the 
larynx and closes up this canal, while the soft palate rises and 
covers the posterior nares. Both these actions serve to prevent 

! Ponton: "Die motorischen Vcrrichtungen des monschlichen Magens," 
Jburg, 1882, p. 127. 



478 DISEASES OF THE STOMACH. 

the contents from reaching either the larynx or the nasal cavity. 
The only canal which remains open is the mouth. From the 
oesophagus, by an antiperistaltic contraction of the same, the 
contents are quickly emptied through the mouth. It is gener- 
ally believed that there exists a centre for the act of vomiting 
in the vagus nucleus. It may even be that the respiratory 
centre and the centre for vtimiting are situated at one and the 
same spot. 

Vomiting may be a consequence of various pathological con- 
ditions of the stomach, or may be due to an abnormal state of 
the food. Nervous vomiting is characterized by the absence 
of either of the two conditions mentioned. 

The vomiting may be due to some spinal or cerebral irritation, 
or may originate reflexly from abnormal conditions in other 
organs (pharynx, oesophagus, larynx, palate, kidneys, liver, 
peritoneum, genital organs, etc.), or it may be due to neuras- 
thenia or hysteria. Among these different kinds of nervous 
vomiting juvenile vomiting and the periodic vomiting of 
Ley den 1 deserve special consideration. 

Diagnosis. — The diagnosis of nervous vomiting has a two- 
fold object in view: (1) To recognize the nervous character of 
the condition, and (2) to reveal, if possible, its cause. Stiller 2 
gives the following points as characteristic of nervous vomiting: 
It occurs easily, without any effort and without any preparatory 
stage. It is, as a rule, independent of the quality and quantity 
of the ingested food. Other points he mentions are: The 
capriciousness with which certain kinds of food (sometimes 
very easily digestible) are ejected, while other indigestible sub- 
stances are well borne; the faculty which sometimes exists in 
selecting only one certain substance from the various food-stuffs 
present in the stomach for the vomiting; the carelessness with 
which the patients bear this condition for a long time; the very 

1 E. Leyden: I. c. 

2 Stiller: "Die nervosen Magenkrankheiten," Stuttgart, 1884. 



NERVOUS VOMITING. 479 

slight or hardly marked degree of inanition, notwithstanding 
the long duration of the ailment. The vomiting is not always 
dependent upon the meals, but may occur occasionally in the 
fasting condition. There exist other neuropathic symptoms, 
which may be associated with the vomiting or alternate with 
it — the influence which psychical conditions exert upon the 
vomiting. To these points Boas 1 adds another one, namely, 
normal secretory and motor functions of the stomach. I 
agree, however, with Bouveret that, while this may be present 
in some cases, there certainly occur cases of nervous vomiting 
in which the gastric secretory function is greatly diminished 
or even absent. 

Juvenile Vomiting. — This condition occurs in young persons 
attending school, especially if they are overworked. Symp- 
toms of cardialgia and vomiting develop, the latter appearing 
either once or twice every day, or presenting a rather periodic 
character. Occasionally there is a train of the following symp- 
toms associated with this vomiting: severe headache, marked 
pallor, very slow pulse, and dilated pupils. The diagnosis of 
this form of vomiting is easily made by the symptoms just 
mentioned. The best treatment is the temporary removal of 
the patient from school, and a good, strengthening diet. 

Periodic Vomiting (Leyden). — Leyden first described periodic 
vomiting, which is characterized by the following points: 1. It 
appears in apparently healthy individuals; 2. The paroxysms 
occur periodically after intervals of equally long duration; 
3. When the attack is over, the patient is perfectly well and no 
gastric symptoms persist. 

The attack is very similar to that of acute succorrhceagastrica 

continua, and may be described as follows: In the midst of 

perfect health the patient experiences for a short time uneasy 

tions -light headache, nausea, slight chilly feeling) which 

arc followed by vomiting. At first the entire gastric contents 

1 Boas: I. c, p. 238. 



480 DISEASES OF THE STOMACH. 

are ejected; later the vomited matter consists of mucus, alone 
or with admixture of either bile or shreds of blood. The latter 
is more frequently found if violent retching has preceded the 
act of vomiting. Frequently, although not always, there exist 
an intense pain in the epigastric region and a sensation of utter 
prostration. The abdomen is, as a rule, sunken and the extrem- 
ities are cold. At this time no food whatever is borne by the 
stomach; even a drink of water is very soon ejected. This con- 
dition of utter irritability of the stomach and persistent vomit- 
ing may last from one to ten days, when suddenly the disturb- 
ances disappear, the nausea subsides, and a feeling of hunger 
returns, which can be satisfied with impunity. All kinds of 
food are now well borne by the stomach, which but an hour 
before could not retain the lightest food. 

The periodic vomiting of Leyden is a rare affection, and it 
does not seem to me that the condition of the gastric secretion 
plays an important part in its causation. While most of the 
cases mentioned in literature seem to have been associated 
with a normal condition of the gastric juice, I have observed a 
case of periodic vomiting in a patient who was affected with 
achylia gastrica. This patient (J. S.), thirty-seven years old, 
had been troubled for the last six years with periodic attacks 
of vomiting, which appeared once in either six or three months 
and lasted from four to five days. During the intervals the 
patient could partake of all kinds of food without much incon- 
venience. The only complaints referred to were frequent 
belching and constipation. During the attacks the patient 
could not ingest anything for the entire five days and as a rule 
presented the most alarming symptoms. I examined him 
frequently during the intervals and also during the attacks 
and never found any traces of gastric juice in the contents. 

The treatment consists in absolute rest, in the administration 
of ice pills, and in the use of morphine (subcutaneous injection) 
or of opium in the form of suppositories. During the intervals 



NERVOUS VOMITING. 481 

between the attacks a sojourn in the country and hydropathic 
procedures may prove of value. 

Reflex Vomiting. — Nervous vomiting frequently occurs as a 
result of derangements of various other organs. Thus abnor- 
mal conditions of the pharynx, an elongated uvula, disorders 
of the genito- urinary organs may be associated with vomiting. 
The vomiting of pregnancy must also be considered as belonging 
to this group. Floating kidney, hydronephrosis, hepatoptosis 
and astigmatism may likewise be the cause of vomiting. 

The treatment of this class of cases will have to be directed 
toward the seat of the original trouble. An elongated uvula 
must be amputated, and ptosis of the different abdominal 
organs must be remedied by keeping them in place b}^ means 
of a suitable bandage. All the genito-urinary disorders should 
be treated as such. The vomiting of pregnancy must be con- 
sidered as a physiological phenomenon as long as it occurs 
during the first months of pregnancy and appears only once or 
twice a day, not interfering much with the general nutrition. 
In this case it is hardly necessary to use any therapeutic means. 
If, however, the vomiting appears more frequently and obsti- 
nately, so that the patient begins to lose in weight, then we 
have the following remedies at our disposal: Bromide of sodium, 
1 gm. (gr. xv.), to be taken twice daily; cerium oxalate, 2 dgm., 
(gr. hi.) three times daily. 

R Menthol, 1.0 

Aq. dest., 100.0 

Spir. frument. recti;., 50.0 

Syr. zingib., 30.0 

D. S. One tablespoonful four times daily. 

Other remedies such as cocaine, codeine, belladonna, or 
chloral hydrate, may occasionally be useful. If medicinal 
treatment fails, then a change of surroundings, as a sojourn in 
the country, may be tried. If all these means prove useless 
and the vomiting continues undiminished, so that the life of 
31 



482 DISEASES OF THE STOMACH. 

the patient is in danger, then as ultimum refugium, artificial 
abortion has to be resorted to. 

Idiopathic Nervous Vomiting.— Besides the above-named 
two groups of vomiting, namely, the juvenile and the periodic, 
which appear without any apparent cause, there exist cases of 
vomiting in adults which do not show any periodicity. The 
vomiting occurs, as a rule, after meals. Usually only a portion 
of the meal is ejected; occasionally, however, the whole meal 
may be vomited. The vomiting may exist for months and 
sometimes even for years without remission. The nutrition, 
as a rule, in these instances is not disturbed. Neurasthenic 
and hysterical individuals form the greater contingent of 
suffers from this form of vomiting. Sometimes, however, 
persons with an apparently normal condition of their nervous 
functions may be affected with this trouble, which is by far 
more frequent in women than in men. 

The treatment consists in regulating the mode of life of the 
patient and in advising him to suppress vomiting whenever 
possible. In neurasthenic and hysterical patients the treat- 
ment must be directed against the original trouble; in others 
change of climate may be tried. Of medicines the bromides 
play a great part. Arsenic and iron are useful in many in- 
stances. In severe cases of vomiting, feeding through the tube 
for a period of two weeks may be restored to. During this 
time no food is to be taken in any other way. When this period 
is over, then small quantities of food are administered per os, 
besides continuing the gavage (feeding through the tube). If 
the food which is taken by the mouth is no longer vomited, then 
after a while gavage may be discontinued and the feeding done 
in the natural way. Intragastric faradization may also prove 
useful. Several cases have come under my observation in 
which nervous vomiting, after having lasted for many years 
and resisted the most diverse modes of treatment, has been, 
perfectly cured by the faradic current. 



PNEUMATOSIS. 483 



Pneumatosis. 



Under the name gastric pneumatosis are classified a group of 
cases in which the stomach is distended with gas (air), giving 
rise to a sensation of marked tension and frequently also to 
shortness of breath (asthma dyspepticum, Henoch). It is 
generally believed that a spasmodic contraction of both the 
cardia and pylorus is partly the cause of this condition. This 
affection may appear periodically or exist constantly. Is is 
often found associated with other symptoms of neurasthenia or 
hysteria : occasionally, however, it is met with alone. In typical 
cases of pneumatosis the epigastric and gastric regions are found 
greatly protuberant , sometimes the upper part of the abdomen 
looks like a balloon. On percussion this area gives a highly 
tympanitic sound. The patients experience a sensation of 
distention and marked want of air; sometimes a feeling of 
utmost anxiety is also present. Belching, as a rule, cannot be 
produced by these patients. 

In making the diagnosis of this condition, it will be necessary 
to exclude organic affections of the stomach which may give 
rise to similar symptoms. In the latter, however, the gas ac- 
cumulated in the stomach will have a foul odor. 

The treatment consists in a general tonic regimen of the 
nervous system and in the adminstration of the bromide salts 
or zinc valerianate. An acute attack of pneumatosis can be 
checked in the quickest and easiest way by the introduction of 
a tube into the stomach, so that the imprisoned air can find an 
exit. The symptoms of tension then disappear at once. This 
procedure must be repeated whenever a considerable quantity 
of gas has accumulated in the stomach and given rise to the 
characteristic symptoms. If a tube is not at hand, or its intro- 
duction be inadvisable, the attack may be relieved by a sub- 
cutaneous injection of morphine (Ewald). The extract of 
Calabar bean may also be found very useful. 



1S1 DISEASES OF THE STOMACH. 

Hypanakinesis Ventriculi. 

I have applied the term hypanakinesis to a condition in which 
the mechanical function of the stomach is greatly reduced. If 
tested with the gastrograph there are found only three or four 
"breaks" and "makes" of the current marked within three 
minutes. Sometimes no current changes whatever are observed 
within the same time. I have noticed this condition several 
times in gastric ulcer, but twice also in persons in which the 
diagnosis of gastric ulcer could be excluded. One of the latter 
usually complained that he experienced the most disagreeable 
sensation soon after meals when resting quietly. He felt 
relieved only when walking about for three-quarters of an hour 
or an hour after each meal. It may be that the exercise which 
the patient instinctively resorted to served to supplement the 
mechanical work of the stomach that was lacking. 

Hyper anakinesis Ventriculi. 

In contrast to the above, hyperanakinesis ventriculi denotes 
a condition of too strong mechanical action of the stomach. 
The gastrograph shows forty to eighty "breaks" and "makes" 
of the current within three minutes. This symptom is fre- 
quently found to be present in cases of obstruction at the 
pylorus, but may occur in other conditions. In several of my 
cases this symptom was associated with hyperchlorhydria. 

Peristaltic Restlessness of the Stomach (Kussmaul 1 ), 
Tormina Ventriculi Nervosa. 

Under this heading are grouped those cases in which there is 
not only an increased motor (mechanical) activity of the stom- 
ach, but in which the peristaltic movements are distinctly 
visible. 

'Kussmaul: "Die peristaltische Unruhe des Magens." Volkmann's 
Samml. klin. Vortrage, No. 181, 1880. 



PERISTALTIC RESTLESSNESS OF THE STOMACH. 485 

In this condition the peristaltic action of the stomach is 
remarkably active. High waves can be seen moving along the 
stomach from left to right. The time required for one wave 
to pass from the extreme left to the pylorus is about one minute. 
This visible peristaltic action of the stomach is more pronounced 
when it is filled with food. In some instances the exaggerated 
peristalsis is felt by the patient as a slightly painful contraction. 
In other instances it is not perceptible to the patient. Peris- 
taltic restlessness of the stomach is usually found in dilated 
stomachs with obstruction of the pylorus. Here it signifies the 
effort winch the stomach makes to overcome the undue resist- 
ance winch the contents find in passing through the stenosed 
pylorus. In rare instances peristaltic restlessness of the stom- 
ach may occur alone without any obstruction of the pylorus, in 
that case being a pure neurosis. Kussmaul has described two 
such cases of nervous origin. I have had the opportunity of 
observing numerous cases of peristaltic restlessness of the 
stomach in stenosis of the pylorus (benign as well as malignant) 
and only two cases of nervous origin. One of the latter was in 
a man, forty-two years old, who presented distinct symptoms 
of neurasthenia and complained of a moving cramp-like sensa- 
tion, winch usually appeared soon after meals in the gastric 
region and lasted for half an hour or longer. On inspecting his 
abdomen half an hour after a light meal, small " mountainous 
waves" could be seen moving from left to right over the gastric 
region. In this case the greater curvature of the stomach 
extended to one finger's breadth above the navel (gastro- 
diaphany) and the stomach was usually found empty one and 
a half hours after a test breakfast. 

The treatment of this affection, if associated with pyloric 
obstruction, must be directed against the latter primary trouble. 
In cases of neurotic origin, our therapeutic measures will have 
to be directed against the nervous system. Massage, hydro- 
therapy, electricity (percutaneous or intragastric faradization), 



486 DISEASES OF THE STOMACH. 

change of climate and surroundings will frequently prove useful. 
Larger doses of potassium bromide and codeine, either alone 
or with belladonna, are often beneficial. 

Antiperistaltic Restlessness of the Stomach. 

Glax, 1 Schiitz, 2 and Cahn 3 have described cases in which the 
waves over the stomach moved from right to left, and they 
therefore designated this condition as " antiperistaltic restless- 
ness of the stomach." Glax's case was of neurotic origin. In 
making the diagnosis of peristaltic or antiperistaltic restlessness 
of the stomach it is of the greatest importance to determine 
that the visible waves originate within the stomach and not in 
the intestines. Peristaltic and antiperistaltic movements of 
the small intestine are frequently observed and can easily be 
distinguished from motions of the stomach by the forms pre- 
sented by the waves. If they originate in the small intestine, 
they are of small calibre (sausage-like) and are seen moving in 
different directions and over different regions, while the waves 
produced in the stomach are nearly always quite large (hand- 
size) and always move, if peristaltic, from left to right, if 
antiperistaltic from right to left, in the upper part of the 
abdominal cavity. 

Incontinentia Pylori (Incontinence of the Pylorus). 

Incontinence of the pylorus was first described by L. de 
Sere 4 and later by Ebstein. 5 The pylorus may be incompetent, 
first, when unyielding neoplasms involve this portion of the 
stomach; secondly, when the pyloric sphincter is in an atonic 
condition, i.e., when the pylorus is apparently always open by 
reason of some nervous derangement. Ebstein diagnoses an 

x Glax: Pest, med.-chirurg. Presse, 1884. 

2 Schutz: Pragermed. Wochenschr., 1882, No. 11. 

3 Cahn: Deutsch. Arch. f. klin. Med., 1884, p. 402. 

4 L. de Sere: "Du Relachement du Pylore." Gaz. des hop., 1864, No. 62. 

6 Ebstein: Deutsch. Arch. f. klin. Medicin, Bd. xxvi, p. 295. 



INCONTINENTIA PYLORI. 487 

incontinence of the pylorus if on inflating the stomach with air 
the latter rapidly passes into the intestine, so that it becomes 
impossible to fill the organ with gas. Instead of the stomach, 
the small intestine then becomes filled with air and gives 
tympanitic sounds on percussion. Ewald justly doubts the 
accuracy of this diagnostic means. He has, indeed, never 
observed this symptom. In all the cases in which he has dis- 
tended the stomach to its utmost extent with air, he could never 
demonstrate that the air passed into the intestine. Whenever 
the tension became too great, the air always escaped upward 
through the cardia with eructation. My own experience coin- 
cides with that of Ewald, although there are exceptions to this 
rule. Incontinence, or rather relaxation of the pylorus, is a 
rare condition, and we are able to recognize it, not so much by 
the fact that food and gas pass from the stomach into the 
duodenum more rapidly than normally, as by the regurgitation 
of intestinal contents into the stomach. The presence of the 
latter condition is shown by the fact that on washing out the 
stomach in the fasting condition, more or less large quantities 
of intestinal juice and especially of bile almost always appear. 
"While the occasional regurgitation of intestinal secretion into 
the stomach may occur as a consequence of irritation caused by 
the tube when lavage is applied, still the quantity of intestinal 
juice is always small. In incontinence of the pylorus, the 
quantity of regurgitated intestinal juice and bile is considerable 
and always present in the fasting condition at each washing of 
the stomach, and sometimes also if the contents of the organ are 
withdrawn one hour after the test breakfast or three to four 
hours after a test dinner. Whether the condition in which the 
stomach becomes empty more rapidly than normally is to be 
referred to a relaxation of the pylorus, or to an increased motor 
function (hyperprochoresis) of the organ, is still undecided. In 
most instances, however, it seems to me that the latter factor 
is the more probable. I have observed two cases of relaxation 



488 DISEASES OF THE STOMACH. 

of the pylorus, and both have been treated by intragastric 
faradization with good results. Occasionally relaxation of the 
pylorus is combined with relaxation of the cardia, as the 
following case well illustrates: 

Miss Emma M , 24 years of age, suffering for three years 

from loss of appetite, eructation, constipation, and poor sleep; 
there was no vomiting but belching of acid fluid after meals. 
One of the worst complaints of the patient was of this highly 
annoying ructus, which never left her, and in consequence of 
which she was hampered in her occupation and frequently kept 
away from society. 

Present Condition. — Tongue thickly coated; splashing sound 
from the stomach to a point two fingers' breadth below the 
navel; the right kidney is clearly palpable and easily moved. 
Examination of the stomach in the fasting condition by means 
of a tube shows that there is bile mixed with gastric juice in the 
stomach; also after the test breakfast the contents of the 
stomach were usually found mixed with bile, as will be seen 
from the following memorandum: 

One hour after the test breakfast: HC1 + ; acidity = 68; ad- 
mixture of bile. 

When fasting, the stomach contains 70 c.c. of an intensely 
yellow-colored fluid (bile present) ; HC1 + . 

The treatment consisted in direct gastro-faradization and once 
in a while washing of the stomach. During the month of April 
the faradization was applied every other day, and the lavage of 
the stomach once a week in the fasting condition. The patient 
felt better after a few days' treatment; the eructation disap- 
peared almost entirely, and she could eat with good appetite, 
having no distress afterward. 

Subsequently the faradization was applied once a week and 
then discontinued. The patient gained several pounds during 
the treatment, and has been pretty free from complaints since 
that time. 

Pylorospasmus. 
A spasmodic contraction of the pylorus without organic 



PYLOROSPASMUS. 489 

disease has been described by Bentejac. 1 He reports the 
following case: 

A man, 59 years old, swallowed a glassful of kerosene by mis- 
take. After this accident he was troubled with intense pains in 
his epigastric region, but never vomited blood nor did he pass 
blood with his movements. At the end of eight months there 
was incessant vomiting and the dilated stomach extended below 
the navel. Stenosis of the pylorus was diagnosed, and Richelot 
performed an exploratory laparotomy, but found the pylorus 
perfectly smooth and normal. The result of the examination 
during the operation proved that the pylorus was only spas- 
modically contracted. The operation, however, had the result 
that the patient ceased to suffer from vomiting, which must be 
ascribed merely to the suggestive effect of the procedure. 

Pylorospasm 2 or spasmodic contraction of the pylorus can 
exist for a short period of time and disappear, or it can make 
its appearance quite frequently and last a long while. Rarely 
pylorospasm exists without any apparent cause (idiopathic 
form . More frequently, however, this condition is secondary 
and due to organic affections in the neighborhood of the pylorus 
(ulcers of stomach or duodenum, gallstones, etc.). The chronic 
form of pylorospasm is a frequent affection, which in its first 
stages is often overlooked. The principal symptoms are pain 
in the epigastric region, sometimes radiating more to the right 
side of the abdomen. Vomiting may exist. In the ^wcn* 
forms of pylorospasm peristaltic restlessness is encountered 
and the pylorus may occasionally be palpated and felt as a 
smooth oval tumor. If ischochymia is fully developed the 
suffering is great and the picture of the disease resembles that 
found in an organic stricture of the pylorus. Such an instance 
of a spastic contraction of the pylorus, simulating an absolute 
benign narrowing of the pylorus, I herewith sketch very briefly. 

: Bentejac: These de Paris, 1888. 

: Max Einhorn: "On Pyloroepasm." Medical Record, Jan. 21st, 1911. 



490 



DISEASES OF THE STOMACH. 



B , about 62 years old, had been troubled with recurrent 

attacks of gastralgia and vomiting for the last five years. Hema- 
temesis three years ago. For the last five months patient was 
never free from distress; he vomited almost every day large 
quantities of highly acid chyme. The stomach extended to 
hand's width below the level. There was peristaltic restlessness 
of the stomach in a marked degree, and the organ in its fasting 
state contained food from the previous day. The symptoms 
becoming steadily more aggravated and patient losing in strength 
and flesh, an operation of gastroenterostomy was performed. 
Patient lived one week and died from symptoms of inanition 







lill 


?^ps 




^K 


fliP 1 !.. 


L 


•|: '''' :: t m: mm<: 


_^ W J 



Fig. 112. — Pyloric portion of the stomach and part of the duodenum of Dr. B. F. B., 
who died in the German Hospital, New York, on December 6, 1908. The pylorus is 
perfectly patent; near it within the stomach is a small round ulcer. 

(persistent vomiting then coma). At autopsy the pylorus was 
found not stenosed, but there existed an ulcer nearby leading 
to absolute pylorospasm. (See Fig. 112.) 



The differential diagnosis between pylorospasm and an 
organic stricture of the pylorus is not easy. The rice test (a 
rice meal given in the evening and followed by gastric lavage 
in the fasting condition the following morning) will always show 
the presence of almost the entire quantity of rice in the stomach 



PYLOROSPASMUS. 491 

in a case of fully developed organic stenosis of the pylorus. In 
pylorospasm, however, the rice test will show different results 
at different times, sometimes the entire quantity being found, 
while at others only a small amount is recovered or nothing at 
all. The duodenal bucket will never reach the duodenum in a 
real narrowing of the pylorus, while in pylorospasm as a rule it 
will do so. The easiest way to recognize whether the bucket 
has passed the pylorus is to ascertain whether the lower part of 
the thread next to the bucket is golden yellow or greenish yellow, 
due to the presence of bile. This, if present, is a positive sign of 
the bucket having passed the pylorus, provided the bile stain 
on the thread extends only for a short distance (10-15 cm.). If 
one-third or almost half of the thread (being 75 cm. long) is bile 
stained, tins would indicate a regurgitation of bile into the 
stomach and would therefore not permit any conclusions 
regarding the passage through the pylorus. 

The treatment of pylorospasm must first be directed to a 
view of eliminating or curing the primary affection; rest cure 
or duodenal feeding for ulcer of the stomach or duodenum, 
removal of gallstones, etc. Such treatment, if carefully carried 
out, very often results in the disappearance of the pylorospasm. 

In those cases in which the pylorospasm is idiopathic, or 
when the primary lesion cannot be entirely eliminated, stretch- 
ing of the pylorus is of value. 

If several attempts to improve the condition have totally 
failed, then surgical interference must be resorted to. Boue 
veret 1 states that pylorospasmus frequently occurs in cases of 
hyperchlorhydria and especially of hypersecretion. The fact 
that in these cases the pyloric region is sometimes found to be 
painful and very tender on pressure, Bouveret refers to an undu- 
spasmodic contraction of the pylorus. I must say that this 
symptom alone is not sufficient to warrant the assumption of 
pylorospasmus. The pains which are felt more to the right 

1 Bouveret: I. c. 



492 DISEASES OF THE STOMACH. 

side may be caused by the undue irritation which too acid 
chyme exerts during its passage through the pylorus. 

Atony of the Stomach. 

Synonyms. — Gastric insufficiency (Rosenbach 1 ); myasthenia 
ventriculi (Boas). 

Atony of the stomach designates a condition in which the 
muscular action of the organ is retarded and weakened. It 
occurs as a frequent complication of many digestive disorders, 
and also of other diseases which greatly weaken the constitution. 
Thus we find it accompanying chronic gastric catarrh, hyper- 
chlorhydria, neurasthenia gastrica, tuberculosis of the lungs, 
grave heart affections, and the like. Sometimes, however, this 
condition exists as a primary neurosis. 

Symptomatology. — If atony occurs as a complication to 
another affection, the symptoms of atony will be overshadowed 
by those of the principal trouble. If it exists alone, the follow- 
ing characteristics are frequently present. An uncomfortable 
feeling of fulness appears after meals; often there is eructation 
of gas; the appetite is diminished; headaches and constipation 
are frequently present. 

Diagnosis. — The diagnosis is based upon the presence of the 
above-described symptoms and the detection of the following 
points on examination: 

1. The splashing sound is easily produced in the gastric 
region, even if the stomach contains only a small quantity of 
chyme or liquid. As a rule, the area over which the splashing 
sound can be produced extends from the margin of the ribs on 
the left side to the umbilicus or somewhat below it. 

2. Six to seven hours after Leube's test dinner, the washing 
out of the stomach reveals the presence of a more or less con- 
siderable quantity of chyme; while the stomach is found empty 
in the morning in the fasting condition. 

1 Rosenbach: Volkmann's Samml. klin. Vortrage, 1878, No. 153. 



ATONY OF THE STOMACH. 493 

3. On filling the stomach with water, the greater curvature 
will descend lower and lower as water is added. This symptom, 
however, which has been described by Pacanowski 1 and Boas, 
is not constant and therefore not reliable. 

The prognosis of atony of the stomach is not bad, as the 
affection is quite amenable to treatment. 

Treatment. — A hygienic way of living and a strengthening 
regime should be advocated. Too much brain work should be 
forbidden, and plenty of outdoor exercise and frequent bodily 
ablutions are to be enjoined. Slow eating and thorough masti- 
cation of the food are of the greatest importance. The quan- 
tity of fluids should be restricted. Xot more than from one to 
one and one-half quarts of liquid, including tea, coffee, milk, and 
soup, should be given daily. As a rule it is best to have the 
patient take five meals a day. The diet should consist of light 
solid food (bread and butter, eggs, mashed and baked potatoes, 
farina, hominy, soup with vermicelli), tender meat (tenderloin 
steak, lamb chops, roast beef, chicken, squab), fish, oysters; 
spinach, asparagus, green peas, carrots; tea, coffee, or cacao 
(with sugar and milk) in small quantities; a small quantity of 
beer or ale. Of medicaments strychnine ranks highest. I 
frequently give tincture mix vomica and fluidextract of con- 
durango equal parts, twenty drops three times daily. The 
administration of ferratin 1/2 gm. three times daily may also 
frequently be found useful. 

Electricity, especially intragastric faradization, seems to me 
to be of the greatest value, in order to strengthen the muscular 
apparatus of the stomach. With regard to lavage, I concur 
with Boas that its use is not indicated in this affection. 

The constipation, which is so frequently present, is best 
treated by having the patient partake of plenty of green vege- 
tables, brown and Graham bread, and plenty of fruit : he should 
be instructed to go to the closel in the morning always at the 

'Pacanowski: Deutsch. Arch. f. klin. Medicin, lid. xl. 



494 DISEASES OF THE STOMACH. 

same time. If these means, however, do not suffice, then I 
frequently order the following pills: 

1} Podophyllin, 0.3 

Extr. nuc. vom., 

Extr. fab. calab., aa 0.5 

Extr. gentian., 

Pulv. glycyrrhizse, aa q. s. 

M. et ft. pil. No. 30. S. One pill twice a day. 

Instead of this pill fifteen to twenty drops of the fluidextract of 
cascara sagrada may be given twice daily. 

Secretory Neuroses. 

The existence of secretory nerves governing the glandular 
secretion of the stomach is generally accepted as a fact, although 
they have not as yet been demonstrated experimentally beyond 
a doubt. Several physiological facts speak in favor of this view : 
A piece of meat held before the eyes of a dog provided with a 
gastric fistula produces a flow of gastric juice. The same 
phenomenon has been observed by Richet 1 in the case of a man 
with a gastric fistula. Fear and great anxiety have a depress- 
ing effect on the gastric secretion. These facts clearly show 
the influence of nerve centres within the brain upon the gastric 
secretory function. There must, however, undoubtedly exist 
some nerve mechanism within the stomach itself which regulates 
the secretion; for after section of the vagus and sympathetic 
nerves supplying the stomach, the latter organ will continue to 
produce its ordinary secretion after the application of an 
irritant. As in the neuroses previously considered, conditions of 
increased and decreased functions exist also in these cases. 

After having described the functional disorders of secretion 
under special chapters (Hypersecretion and Achylia Gastrica), 
we need say here only that in most instances these affections 

1 Ch. Richet: "Du Sue gastrique chez l'Homme et les Animaux," Paris, 
1878. 



XERVOUS DYSPEPSIA. 495 

are of nervous origin, either protopathic or of a reflex nature. 
Tins latter theory has been especially advocated by Charles G. 
Stockton, 1 of Buffalo. 

Frequently, however, disorders of secretion may secondarily 
accompany primary neuroses; thus tabes dorsalis and other 
spinal lesions are frequently associated with hyperchlorhydria 
and also with periodic gastrosuccorrhcea. 

Neurasthenia and hysteria may be complicated with either 
hyperchlorhydria or hypochlorhydria or achylia. The symp- 
toms which these secretory disturbances evoke are the same as 
if they were the primary affections. 

Hypochlorhydria of nervous origin is sometimes met with 
without the association of other nervous symptoms, and it is 
then quite difficult to establish the diagnosis between this 
affection and gastric catarrh. Absence of tenderness on pres- 
sure in the gastric region and a perfectly clean tongue point 
rather to the presence of a neurosis. Sudden changes in the 
condition of the gastric secretion (heterochylia [Hemmeter]) 
speak likewise in favor of a neurotic character. 

Nervous Dyspepsia 2 (Leube). 

Leube 3 originated the name of nervous dyspepsia (neuras- 
thenia gastrica of Ewald) to describe a condition characterized 
by manifold subjective symptoms, which appear during the act 
of digestion, but cannot be referred to any abnormal condition 
in the organ susceptible of objective demonstration. All cases 
in which dyspeptic symptoms existed and in which after a test 
dinner hydrochloric acid was detected and the organ was found 
empty seven hours after this meal, Leube diagnosed as nervous 

'Charles G. Stockton: Medical Record, 1894. 

- Nervous dyspepsia is in reality a mixed neurosis in which the sensory, 
motor, and secretory nerve mechanism, either combined or alternately, 
may play a part. 

'Leube: "Ueber nervose Dy-pf-p-if." Deutsch. Arch. f. klin. Medicin, 
Bd. xxiii, L879. 



490 DISEASES OF THE STOMACH. 

dyspepsia. Later, when attempts were made to estimate the 
degree of acidity quantitatively, all the cases of hyperchlor- 
hydria had to be separated from this condition. For here the 
subjective complaints of the patients could be referred to the 
abnormal condition existing in the undue secretion. Nervous 
dyspepsia may best be characterized by the existence of mani- 
fold clinical symptoms, without any organic lesion whatever. 

Etiology. — The disease appears more frequently in men than 
in women. Although it may occur at the most diverse ages, 
still the years between thirty and forty-five show the greatest 
frequency. Many debilitating conditions give rise to the 
development of this trouble: chlorosis, lung troubles, grippe, 
malaria; abnormal conditions of the genito-urinary organs, 
sexual excess, excessive use of tobacco and alcohol predispose 
to this affection. Organic troubles of the stomach, such as 
ulcer or chronic gastric catarrh, may also give rise to this com- 
plication. It is hardly necessary to say that both neurasthenia 
and hysteria are often complicated with nervous dyspepsia, or, 
speaking more correctly, the nervous dyspepsia in reality forms 
a part of these two conditions. 

Symptomatology. — The appetite is generally irregular and 
capricious. Sometimes it is increased, more frequently, how- 
ever, it is lessened. The tongue, as a rule, is clean and only 
occasionally slightly coated. Very soon after a meal various 
symptoms appear: slight pains in the gastric region, frequent 
belching, sometimes an irresistible desire to sleep, occasionally 
a feeling of burning in the head, especially in the forehead. 
All these disagreeable sensations frequently last as long as there 
is food in the stomach. Sometimes, when the stomach is 
empty, a weak feeling and slight dizziness overcome the patient, 
so that there is really no time whatever during which the 
patient feels perfectly well and enjoys the feeling of a healthy 
person. This explains the marked depression existing in these 
patients. Most of them look at everything from the darkest 



NERVOUS DYSPEPSIA. 497 

point of view, and any small inconvenience, which would hardly 
be noticed by a healthy person, may give them great anxiety 
and fear. At first the nutrition of the body appears to be in 
good condition. But sooner or later the patient begins to lose in 
weight, the sleep is also very soon impaired, and all the symp- 
toms are aggravated. 

Besides the gastric symptoms there are also manifold symp- 
toms winch refer to the intestines. Sensations of fulness or of 
tension, and sometimes also pain, are experienced in different 
regions of the abdomen. Frequently these abnormal sensations 
are caused by an accumulation of gas in the intestinal tract and 
relief is felt after the passing of flatus. The bowels are almost 
always constipated. The movements sometimes appear in 
the form of small balls and occasionally in the form of a very 
thin long cylinder the size of a quill. The latter is always the 
result of the spasmodic form of constipation. Diarrhoea is 
very seldom met with in this disease. 

Burkhart 1 has described the existence of certain points in 
the abdomen which are painful to pressure, and believes them 
to be characteristic of tins affection. Leven 2 likewise attributes 
great importance to the appearance of these painful spots, 
which he ascribes to an irritation of the solar plexus. He 
describes three such painful areas, one immediately below the 
ensiform- process, the others near the navel, especially to the 
left of it. Ewald, Richter, 3 and Bouveret are of the opinion 
that this symptom is by no means characteristic of nervous 
dyspepsia, as they have met with cases of the affection in which 
iK) such painful points could be found. The condition of the 
gastric juice does not present anything characteristic of this 
affection. Frequently the juice will be found normal. Some- 
times the degree of acidity will be diminished and occasionally 

1 Burkhart: "Zur Pathologio dor Xourasthonia gastrica," Bonn, 1882. 

2 Leven: "Estom&c et Cerveau," Paris, 1884. 
'Richter: Berl. klin. Wochenschr., 1882. 

32 



498 ' DISEASES OF THE STOMACH. 

increased. In many cases the condition of the gastric juice 
will reveal manifold variations from time to time. I agree with 
Bouveret that more frequently a diminished acidity is met 
with in this affection. If the affection has lasted quite a w T hile, 
atony of the stomach is usually present. In women enterop- 
tosis very frequently occurs as a complication. In both sexes, 
but more frequently in the female, membranous colitis may 
develop in consequence of the high degree of constipation and of 
the irritation of the colon through scybala. Besides all these 
symptoms, which refer to the digestive tract, manifold nervous 
symptoms usually occur: headache, insomnia, pains in the back, 
frequent emissions, sometimes impotence, vertigo, palpitations 
of the heart after slight exertions or after meals, feeling of 
extreme weakness, loss of energy and ambition, etc. 

The prognosis of neurasthenia gastrica is quite uncertain. 
Cases of a slight nature may sometimes resist the best kinds of 
treatment for a long time. On the other hand, cases of a severer 
nature may readily yield to rational treatment. The duration 
of the disease can very seldom be foretold, and although life is 
not directly endangered, still instances of fatal issue even 
wdthout apparent complications have been reported in 
literature. 

Diagnosis. — The presence of symptoms of general neuras- 
thenia, and especially of those attributable to the digestive 
tract without the existence of a real organic trouble, will estab- 
lish the diagnosis. The principal characteristic of this affec- 
tion is the lack of proportion between the multiform complaints 
and the results objectively found in an examination of the 
digestive organs. Another point of value is the circumstance 
that different kinds of food, even indigestible substances, do 
not seem to aggravate the condition, nor does very light food 
ameliorate it, while changes of climate or surroundings or 
sometimes pleasant news and the like, may suddenly check all 
the unpleasant sensations for a considerable time. 



NERVOUS DYSPEPSIA. 499 

Differential Diagnosis. — Neurasthenia gastrica may occa- 
sionally be confounded with chronic gastric catarrh, ulcer of 
the stomach, or cancer, the more so as' all these organic affec- 
tions of the stomach are frequently associated with nervous 
symptoms. The following points will serve to differentiate 
between neurasthenia gastrica and the affections mentioned: 
in neurasthenia gastrica the nervous symptoms (referring to 
the stomach and to other distant organs) play the most import- 
ant part. While the different complaints are connected more 
or less with the digestive tract, the quality and quantity of 
food do not seem to be of great importance. Sudden changes 
in the condition of the patient, who feels entirely well for a few 
days and then again utterly disabled, are characteristic of 
neurasthenia gastrica. Chronic gastric catarrh will be easily 
recognized by the constancy of the symptoms, which are aggra- 
vated by errors in diet, and by the condition of the gastric 
secretion (diminished acidity, large quantity of. mucus, etc.). 
In ulcer of the stomach we shall always find some of the char- 
acteristic points (circumscribed painful spot, vomiting, haema- 
temesis or melsena, pains after the ingestion of food, as a rule 
very intense). As is well known, however, an ulcer may exist 
without any of these characteristic symptoms, and it therefore 
becomes very difficult to exclude its presence, the more so as 
neurasthenia gastrica may complicate this affection. To estab- 
lish the differential diagnosis between neurasthenia gastrica 
and cancer of the stomach, it is often necessary to have the 
patient under observation for quite a period of time. When- 
ever there is a tumor or other distinct symptoms of cancer, it is 
easy to recognize the cancerous affection. If, however, marked 
symptoms are absent (during the first period of the disease), 
the differential diagnosis is difficult. In cancer of the stomach 
there will also be some relation between the quality and quan- 
tity of the ingesta, and the existing disturbances. Moreover, 
in cancer of the stomach there Is progressive aggravation of the 



500 DISEASES OF THE STOMACH. 

trouble, while in neurasthenia gastrica the condition may re- 
main stationary for a long period of time. 

Treatment. — In all cases in which some connection can be 
found between this affection and other existing ailments, the 
treatment must be directed against the latter. If neurasthenia 
gastrica exists alone, then therapeutic means must be resorted 
to which will strengthen the entire nervous system. Change 
of climate, outdoor life, entire relief from business cares, are of 
great importance, and sometimes sufficient to cure the patient. 
The diet should be ample, and it is of importance to impress 
upon the patient the necessity of taking plenty of food. As to 
the digestibility of different lands of food in this affection, the 
patient's own judgment and experience are the best guides to 
follow. Condiments should be taken moderately and the use 
of wine, tea, coffee, and beer in small quantities is allowable. 
In patients who have greatly emaciated, Weir Mitchell's rest 
cure is often followed by the best results. The direct means 
which serve to strengthen the nervous system are the following: 
1. Hydrotherapeutic measures of a mild nature (wet cold pack, 
lukewarm sitz bath). 2. Massage of the entire body, to which 
special massage of the abdomen may be added. 3. Electricity; 
general faradization of Beard and Rockwell; 1 the patient sits 
barefooted on a large plate electrode, while the other electrode is 
passed by the physician over the chest, back, and extremities — 
electric bath. 4. Both sleep and rest should be accorded to 
the patient in a large degree. While gymnastic exercises are 
beneficial, they should never be indulged in to such an extent 
as to tire out the patient. 

With reference to the local treatment of the stomach, the 
gastric douche has been recommended by Malbranc 2 and lately 
by Rosenheim. 3 In a few cases I have applied the gastric 

1 Beard and Rockwell: I. c. 

2 Malbranc: I. c. 

3 Th. Rosenheim: Therap. Monatshefte, 1892, p. 382. 



NERVOUS DYSPEPSIA. 501 

spray with similar good results. As regards medicaments, the 
bromides are of the greatest importance. 

R Ammonii bromidi, 

Sodii bromidi aa 1.0 

M. f. pulv. D. in chart. Xo. 20. S. One powder twice daily in 
milk or in water. 

The use of the different tonics (iron, arsenic) is frequently 
indicated. Levico or Roncegno water (one-half to one table- 
spoonful three times daily), ferratin, triferrin, Glide's pepto- 
mangan, Dietrich's peptonate of iron, ovoferrin, are also in 
place. In cases in which the anorexia plays a dominant part, 
tincture of nux vomica (ten drops three times daily) or orexi- 
num basicum (2 dgm. in wafers, three times daily) should be 
administered. Insomnia will often have to be remedied by the 
use of either chloral hydrate, sul phonal (1 1/2 to 2 gm.), trional 
(1 to 2 gm.), or veronal (0.5 to 1.0 gm.). 

The bowels should be regulated according to the rules given 
in the chapter on chronic gastric catarrh. A sojourn in the 
mountains or in some watering-place having mild ferruginous 
springs, such as Elster, Franzensbad, and Pyrmont, or salines 
such as Ems, Wiesbaden, and Kissingen, may be recommended, 
while the purgative waters of Carlsbad and Marienbad should 
be avoided. 



CHAPTER XIV. 

THE CONDITION OF THE STOMACH IN DISEASES OF 
OTHER ORGANS. 

There are but few diseases which are not attended to a 
greater or less extent with gastric symptoms. Every consti- 
tutional or local disease, febrile and afebrile processes, are all 
more or less complicated with disturbances of the digestive 
organs. The digestive symptoms in all these conditions, how- 
ever, are dependent upon a general disturbance of the entire 
organism and are not due to real affections of the digestive 
organs. They are therefore always discussed in the symptomat- 
ology of the different diseases. In the following we shall 
briefly describe the condition of the stomach in several organic 
diseases of other organs, wherein the gastric symptoms play 
a predominant part. In fact, in many cases it is quite difficult 
to recognize the secondary nature of the gastric trouble, the 
primary disease giving so few and unimportant symptoms that 
it is easily overlooked. 

Tuberculosis of the Lungs.— As is well known, in pulmonary 
tuberculosis the symptoms of the gastro-intestinal tract are 
frequently very pronounced and very difficult to manage; often 
there exist loss of appetite, disagreeable sensations after meals, 
belching, bad taste, constipation alternating with diarrhoea, and 
last, but not least, severe and obstinate gastralgia as well as 
enteralgia. While these gastric symptoms, as a rule, appear 
when the tuberculous process in the lungs is already quite 
advanced, occasionally they may exist long before there is any 
evidence of a real lung trouble. While the pathological 
anatomy of the stomach in tuberculous patients has been 

502 



THE STOMACH IN OTHER DISEASES. 503 

examined by W. Fen wick, 1 who found well-marked evidence of 
gastric catarrh in eleven out of fifteen cases of phthisis, the 
functions of the stomach in this affection have been studied by 
Rosenthal. 2 Edinger, 3 Klemperer 4 and Schetty, 5 Brieger, 6 
Hildebrandt, 7 Immermann, 8 and myself. 9 My own conclusions, 
which harmonize well with those of most of the writers just 
mentioned, were published in the Medical Record of May 4th, 
1889, and are as follows: 

1. Among the fifteen cases of phthisis pulmonum examined, 
free hydrochloric acid was absent in two only (Xos. 14 and 15); 
in a third patient (Xo. 11) the hydrochloric acid was wanting 
but once, and was present at two other examinations; in all the 
other patients the hydrochloric acid was always present. 

2. As regards acidity, in five patients (Xos. 6 to 10) it was 
found normal: five (Xos. 1 to 5) showed hyperacidity; and 
five (Xos. 11 to 15), a diminution in the degree of acidity; 
among the last group there were two with a total absence of 
free hydrochloric acid. 

3. Only one patient (Xo. 4) had in his stomach, after the 
test breakfast, the remnants of the yolk of an egg which he had 
eaten on the day previous, and that but once. In all other 
patients no food whatever was found in the stomach except 
the fine pieces of the roll. The stomach must have been empty 
before taking the breakfast, and therefore it can be concluded 
that the motor power of the stomach was not diminished in a 
very high degree. 

1 W. Fenwick: Virchow's Arch., 1889, p. 187. 

2 C. Rosenthal: Berl. klin. Wochenschr., 1888, Xo. 45. 

3 Edinger: Deutsch. Arch. f. klin. Med., 1881. 

4 Klemperer: Berl. klin. Wochenschr., 1880, Xo. 11. 

5 F. Schetty: Deutsch. Arch. f. klin. Med.. Bd. xliv, p. 210. 

6 Brieger: Deutsch. med. Wochenschr., 1888, Xo. 1 I. 

7 Hildebrandt: ibidem, 18S0, Xo. 15. 

% Immermann: Verhandl. dee Congresses f. [nnere Median Wiesbaden, 
1889. 

9 Max Einhorn: Medical Record, May 4th, 1889. 



504 DISEASES OF THE STOMACH. 

4. In most cases a record of the appetite was kept. A 
priori, one would be inclined to think that the appetite is in a 
certain degree dependent upon the amount of gastric juice 
secreted. As the amount of gastric juice secreted is measured 
by the degree of acidity, the appetite ought to be good where 
hyperacidity or a normal amount of acidity exists, and bad where 
there is present a diminished degree of acidity. But this is 
not true; three patients with hyperacidity (Nos. 1, 3, and 4), 
and two with normal acidity (Nos. 8 and 10), complained of 
poor appetite, whereas patient No. 15 had a good appetite, 
although there was complete absence of free hydrochloric acid 
in his stomach. 

It will be seen that frequently the subjective symptoms do 
not harmonize with the objective data found in a thorough ex- 
amination of the stomach. The point to be gained from this fact, 
with regard to treatment is not to be afraid of giving sufficient 
food to these patients with markedly disturbed appetite and 
many other dyspeptic symptoms. In fact, gavage or forced, 
alimentation will often prove very useful. Debove, Peiper,, 
Ley den, and others have obtained the most beneficial results in 
phthisical patients by this method. 

The treatment of the gastric symptoms, in which certain 
functional anomalies of the stomach (as for instance hyper- 
chlorhydria or hypochlorhydria) have been found, will be 
similar to that described under the head of these latter condi- 
tions. The main treatment, however, must always be directed 
against the primary affection, namely, the lung trouble. 

Tuberculous ulcers of the stomach are occasionally met with, 
especially in association with tuberculous lesions of other 
organs. Their occurrence has been described by several writers. 
(Eppinger, 1 Litten, 2 Musser 3 ). 

1 Eppinger: Prag. med. Wochenschr., 1881, Nos. 51 and 52. 

2 Litten: Virch. Arch., Bd. lxvii, p. 615. 

3 Musser: Philad. Hospital Reports, 1890, vol. i, p. 170. 



THE STOMACH IX OTHER DISEASES. 505 

Syphilis of the Stomach. — Dyspeptic symptoms not infre- 
quently occur in the secondary and tertiary stages of syphilis. 
While in the secondary stage, however, the digestive disturb- 
ances are attributable to the constitutional condition, to the 
fever, etc.. and hence are to be regarded as concomitant phe- 
nomena of the original disease, without any special involve- 
ment of the stomach, the affections of the stomach in the ter- 
tiary stage of syphilis are of independent nature, caused by 
anatomic processes in that organ. 

The lesions of the stomach during the tertiary stage of 
syphilis may assume various forms (erosions, ulcers, tumors, 
stenosis of the pylorus, gastralgia, etc.), all of which present the 
features of the ordinary types of these affections; their syphi- 
litic nature cannot be recognized by the symptoms alone. 
Diagnosis of then syphilitic origin is facilitated, first, by the 
demonstration of a previously existing luetic infection; secondly, 
by syphilitic manifestations in other portions of the body; 
thirdly, by the presence of Wassermann's reaction, and fourthly, 
by the successful results of antisyphilitic treatment. 

It is scarcely necessary to mention that syphilitic subjects 
may suffer from any of the diseases of the digestive tract 
without there being any connection between the latter and 
antecedent lues. Indeed, these cases probably constitute 
the majority. Hence it is the more difficult to decide in any 
given case whether the disease of the stomach is of syphilitic 
nature or not. Yet this is quite often possible. 

Syphilis of the stomach has been observed by Andral, 1 
Wagner, 2 Lancereaux, 3 Cornil, 4 Chiari, 5,6 Stolper, 7 Gaillard, 8 



Andral: Clinique medicale, Paris, 1834, t. ii., pp. 90, 201-207. 

2 E. Wagner: "Das Syphilom, oder die constitutionelle syphilitische 
Neubildung." Archiv f. Heilkunde, Bd. iv., p. 225. 

3 Lancereaux: "Traite de ]a syphilis," I860, p. 406. 

* V. Cornil: "Lemons Bur la Syphilis," Paris, 1879, p. 406. 
EL Chiari: "Lues hereditaria mit gummdser Erkrankung dee galle- 



506 DISEASES OF THE STOMACH. 

Mracek, 1 Osier, 2 Hemmeter, 3 Dieulafoy, 4 Fournier, 5 Flexner, 6 
Mackay, 7 Fraenkel, 8 Aristoff, 9 and myself. 10 

Among the cases which I have observed it is best to differen- 
tiate three groups of syphilitic diseases of the stomach, namely: 
I. Gastric ulcer of syphilitic origin. 
II. Syphilitic tumor of the stomach. 

III. Syphilitic stenosis of the pylorus. 

Group I. (syphilitic ulcer of the stomach) is chiefly repre- 
sented clinically in the literature. I have observed two cases 
belonging to this class. In the first case (Mrs. A. K.) other 
signs of tertiary syphilis existed, while in Case 2 (Carrie W.), 
aside from the lesion of the stomach, nothing further of luetic 
nature could be found. In both cases the customary methods 

leitenden Apparates und des Magens." Prager med. Wochenschrift, 1885, 
No. 47, S. 461. 

6 Chiari: " Ueber Magensyphilis." Festschrift f. R. Virchow, 1891, ii., 
p. 297. 

7 Stolper: " Beitrage zur Syphilis visceralis." Bibliotheca Medica, 1896, 
C, Heft 6. 

8 L. Gaillard: Archives generates de Medecine, 1896, i., pp. 66-83. 

1 F. Mracek: "Lehmann's med. Handatlanten," Bd. vi., " Syphilis und 
venerische Krankheiten, " Munchen, 1898, p. 52. 

2 W. Osier: "The Principles and Practice of Medicine," New York, 1891, 
p. 178. 

3 J. C. Hemmeter: "Diseases of the Stomach," 1897, p. 556. 
4 Dieulafoy: "Syphilis de l'estomac." Bulletin de l'Academie de 

Medecine, 1898, No. 20, p. 578. 

6 Fournier: Cited by Dieulafoy, loc. cit. 

6 Simon Flexner: "Gastric Syphilis, with Report of a Case of Perforating 
Syphilitic Ulcer of the Stomach." American Journal of the Medical 
Sciences, 1898, N. S., cxvi., p. 424. 

7 W. A. Mackay: "The Role of Syphilis in the Etiology of Simple Ulcer of 
the Stomach." Lancet, 1898, ii., p. 1701. 

8 E. Fraenkel: "Zur Lehre von der acquirirten Magen-Darm Syphilis.' 
Virchow's Archiv, Bd. civ., p. 507, 1899. 

9 Aristoff*: "Zur Kenntniss der syphilitischen Erkrankungen des Magens 
bei hereditarer Lues." Zeitschrift f. Heilkunde, 1898, xix., p. 395. 

10 Max Einhorn: "Syphilis of the Stomach." Philadelphia Medical 
Journal, February 3d, 1900. See also, Max Einhorn: "Ein Fall von Syphi- 
litischer Geschwulst des Magens." Munch, med. Wochenschr., 1902, 
No. 48. 



THE STOMACH IN OTHER DISEASES. 507 

of treatment of gastric ulcer were entirely or partially unsuc- 
cessful, while antisyphilitic therapy was followed by complete 
recovery. 

The second group (syphilitic tumors of the stomach) has 
received but scant mention in the literature, as far as I have 
been able to learn, except in a few reports of autopsies, but has 
not been described as having been recognized during the life- 
time of the patient. I have described two cases (C. K. and 
William C.) belonging to this group. The occurrence of syphi- 
litic tumors of the stomach is quite rare, but none the less 
important. They may run their course in a similar manner as 
carcinoma, and readily be mistaken for the latter. On palpa- 
tion such a gummatous tumor may evince all the characteristics 
of a malignant neoplasm, and even the symptoms may so 
strongly resemble those of cancer as to be confounded with the 
latter. It would appear, therefore, advisable in every case of 
neoplasm of the stomach to bear in mind the possibility of 
syphilis, and to question the patient as to any previous history 
of that disease, and examine for any other syphilitic manifesta- 
tions on the body. As an illustration of this group I shall 
describe one of my recently observed cases reported 1 in the 
International Journal of Surgery. 

Dr. Edw. S., dentist, 34 years of age, consulted me June 24, 
1 003. He had a chancre seven years ago, and was treated for it; 
two years ago he had pains in the larynx, which disappeared 
under antisyphilitic treatment. Six months ago he began to 
complain of distress in the stomach (belching, bad taste in the 
mouth), as well as moral and psychic depression. He was unable 
to work, and lost about twenty pounds in weight. His sleep was 
disturbed and he complained of pains in the shoulders and ribs. 
Although formerly always constipated, he now had diarrhoea. 

Status prcesens. — The patient looks emaciated and is very 
anaemic. Examination of the thoracic organs is negative. The 

'Max FJnhorn: "A Case of Syphilitic Tumors of the Stomach and 
Liver with Recovery." International Journal of Surgery, January, 100!). 



508 DISEASES OF THE STOMACH. 

stomach is much dilated and extends two fingers' width below 
t he navel. In the pyloric region a tumor the size of a goose-egg 
and involving the anterior wall of the stomach can be felt; its 
surface is smooth. Examination of the stomach contents reveals 
a practically normal condition of the gastric juice and no 
ischochymia. 

The liver dullness begins a finger's width below the right 
mamilla and extends to two fingers' width below the costal mar- 
gin. To the right of the mammillary line a lump the size of a 
walnut can be felt on the surface of the liver. 

The patient is put on iodide of sodium and a week later — 
when the tumor of the stomach appeared rather larger — on 
mercury inunctions. 

July 3d and 10th, patient feels a little better, but the tumor is 
unchanged. 

Oct. 9, patient has continued the antiluetic treatment for two 
months. He has gained twelve pounds in weight, complains of 
nothing, and feels perfectly well. 

Objectively, no trace of the former tumors can be demonstrated; 
the stomach reaches only to a finger's width above the navel, and 
the liver does not project beyond the right costal margin. 

In view of the previous syphilitic history, with subsequent 
tertiary lesions in the larynx, it was easy to make a probable 
diagnosis of gummata of the stomach and liver. The results of 
the chemical examination of the stomach contents also corre- 
sponded more to this than to a malignant neoplasm, for in the 
latter class we find marked changes in the gastric juice in the 
majority of cases, whereas here it was normal. 

The diagnosis was, however, positive only after antiluetic 
treatment had caused the tumors to disappear and had resulted 
in complete recovery. 

The third group of syphilitic pyloric stenosis is of great 
practical import. In one of the cases I have observed (Carl S.) 
a thickened pylorus could be felt as an oval tumor which dis- 
appeared under continued antisyphilitic treatment. At the 
same time the symptoms of ischochymia receded and the 
patient recovered. In a second case (George W.) the pylorus 
was not palpable, and the diagnosis of the commencing con- 



THE STOMACH IN OTHER DISEASES. 509 

striction had to be based upon the results of internal examina- 
tion of the stomach. In both cases the customary medical 
measures indicated in benign pyloric stenosis proved insufficient 
while the administration of potassium iodide soon effected the 
improvement. Siegheim 1 has just reported a case belonging 
to tins group, in which HC1 was absent and lactic acid present. 
A cure resulted after antiluetic treatment. 

[A fourth group of syphilitic cirrhosis of the stomach has 
recently been described by Kemp. 2 The stomach was small, 
hard, and contracted, and on palpation felt like a cirrhotic 
carcinoma, involving the entire stomach.] 

From the remarks just made it appears distinctly that tertiary 
syphilis may produce severe gastric affections which are suscep- 
tible to antiluetic treatment. In the therapeutics of intracta- 
ble diseases of the digestive apparatus, therefore, the possibility 
of a syphilitic origin of the trouble must never be forgotten. 

Diseases of the Blood. — In chlorosis and anaemia the gastric 
symptoms frequently play an important part. They all, as a 
rule, belong to the neurotic derangements of the stomach. 
Thus anorexia, gastralgia, hyperesthesia of the stomach, atony, 
and hyperchlorhydria are frequently met with. Some writers 
(Hayem 3 and others) look upon the gastric disturbances as the 
primary factor causing the affection of the blood. I concur 
with Ewald and Rosenheim that in the vast majority of cases 
the digestive symptoms are only sequelae and not the primary 
cause of the chlorosis. The administration of iron quickly 
improves the gastric symptoms. 

Heart lesions are frequently attended with gastric disturb- 
ances. The latter, as a rule, are due to hyperemia of the gas- 
tric mucosa and consist in a feeling of pressure in the epigastric 



3 -^heim: " Ueber Syphilis des Magens." Deutsche med. Wochenschr. 
1911, p. 149. 

- R. C. Kemp: "Diseases of the Stomach and Intestines," 1910, p. 393. 
3 Hayem: Bull, medical, 1891, Xo. 87. 



510 DISEASES OF THE STOMACH. 

region, especially after meals, anorexia, belching, etc. Hue- 
flerV assertion that there is an absence of free hydrochloric acid 
in almost all cases of valvular heart lesions is not correct, as has 
been shown by myself 2 and later by Adler and Stern. 3 Among 
twelve patients with heart affections whose gastric contents I 
have examined, in eight free hydrochloric acid was present, 
while in four it was absent. 

Gastric affections not infrequently produce symptoms simu- 
lating a heart lesion. Thus, for instance, arrhythmia cordis, 
tachycardia, and occasionally bradycardia are met with in 
chronic gastric catarrh, in nervous disorders, and in atony of 
the stomach. Sometimes it is difficult to decide at first whether 
we have to deal with an affection of the heart or of the stomach. 
A thorough examination of the circulatory apparatus and also 
of the gastric functions will reveal the true nature of the 
disease. 

Dyspeptic Asthma. — Asthma, due to digestive disturbances, 
was first described by Henoch 4 under the name of asthma 
dyspepticum. The original communication of this clinician 
referred to its occurrence during acute digestive disturbances in 
children. His cases all ran their course under alarming symp- 
toms — the dyspnoea being of a high degree and attended with 
cyanosis and cold extremities — and failed to improve under the 
ordinary stimulants, but entirely recovered after a treatment 
directed against the disturbances of the digestive tract. 

Silbermann, 5 Barie, 6 Lauterbach, 7 Oppler, 8 Boas, 9 Ehrlich, 10 

1 Huefler: Mtinchen. med. Wochenschr., 1889, No. 33. 

2 Max Einhorn: Berl. klin. Wochenschr., 1889, No. 48. 

3 Adler und Stern: Berl. klin. Wochenschr., 1889, No. 49. 

4 Henoch: "Ueber Asthma dyspepticum." Berl. klin. W'ochenschr., 
1876, No. 18, p. 241. 

5 Oscar Silbermann: "Zur Lehre vom Asthma dyspepticum der Kinder." 
Berl. klin. Wochenschr., 1882, No. 23, p. 348. 

°E. Barie: "Recherches cliniques sur les accidents cardiopulmonaires 

consecutifs aux troubles gastrohepatiques." Revue de Medecine, hi., 1883. 

7 M. Lauterbach: "Asthma dyspepticum in Folge atonischer Verdauungs- 



THE STOMACH IN OTHER DISEASES. 511 

Murdoch, 1 and myself 2 have written on this subject. 

Cases of dyspeptic asthma can conveniently be classed into 
two main groups: (1) Cases in which dyspeptic asthma appears 
in an acute form, periodically; (2) cases in which dyspeptic 
asthma assumes a more chronic type. 

The first group is characterized by the occurrence of attacks 
of asthma at more or less prolonged intervals, either without an 
apparently preceding cause or after distinct excesses in eating, 
drinking, smoking, or after undue excitement. The attack is 
usually of a very severe type, often assuming alarming symp- 
toms — extreme dyspnoea, cyanosis, almost collapse. 

The second group, that of chronic dyspeptic asthma, embraces 
the larger number of cases, and may again be divided into two 
separate categories: (a) cases in which the attacks of asthma 
appear quite soon after meals, either without any particular 
provocation of after some slight exertion; (6) cases in which 
the attacks usually occur two or three horns after meals, 
either spontaneously or again after some exertion — walking, 
etc. In a certain number of the latter category the attacks can 
be checked by partaking of a small amount of food. 

Cases belonging to category (a), of group 2, resemble very 
much true angina pectoris, which is so often encountered in 
arteriosclerosis of the coronary arteries. Their differentiation 
from the latter is often very difficult. For even in true angina 
pectoris at the beginning there will be attacks without any 



schwache." Wiener med. Presse, 1894, Xo. 48, p. 1841. 

8 B. Oppler: " Ueber Asthma dyspepticum." Allgem. med. Central- 
Zeit., 1896, Xo. 71, p. 849. 

9 J. Boa-: " Ueber Asthma dyspepticum." Arch, f . Verdauungskrankh., 
Bd. ii.. 1896, p. 444. 

I . Ehrlich: " Casuistischer Beitrag zum Asthma dyspepticum." Arch. 
f. Verdauungskrankh.. Bd. v.. 1899, p. 126. 

1 F. H. Murdoch: "Dyspeptic Asthma." New York Medical Journal, 
January 12th. 1901, p. 58. 

2 Max Einhorn: "Dyspeptic Asthma." The Journal of the American 
Medical Association. February 1st, 1902. 



512 DISEASES OF THE STOMACH. 

discoverable lesions of the heart or blood-vessels. Such cases 
may for a long time appear as dyspeptic asthma until all of a 
sudden there are distinct signs indicating the heart involve- 
ment, as, for instance, a sudden appearance of albumin in the 
urine or irregularity of the pulse, etc. 

The differentiation between dyspeptic asthma belonging to 
this category and true angina pectoris is not always easy. As 
a rule, however, cases of dyspeptic asthma are amenable to 
treatment; that means that a rational regime with regard to 
the digestive apparatus is followed by good results. These 
cases also are often capable of a permanent cure. Cases of 
angina pectoris, however, caused by cardiac lesions — if the 
latter are not manifest — are much less amenable to treatment, 
and if improved, the amelioration is only transient. 

A great many of my cases of dypseptic asthma have been 
examined with regard to the secretory condition of the stomach. 
Although no constant anomalies were found, it is noteworthy 
that a considerable number of the patients suffered from achylia 
gastrica; hyperchlorhydria likewise was often encountered. In 
both these conditions a rational treatment of the gastric affec- 
tion was frequently crowned with favorable results as far as 
the disappearance of asthma was concerned. The explanation 
why two such contrary conditions may produce the same phe- 
nomenon may be found in the fact that in both probably an 
undue irritation of the gastric mucosa takes place. In hyper- 
chlorhydria it is the hyperacid gastric juice, in achylia the 
mechanically unchanged coarse particles of food, which irritate 
the mucous membrane of the stomach and thus reflexly the 
vagus fibres. 

In those cases in which the gastric secretion is more or less 
normal it will be necessary to assume a condition of hyper- 
esthesia of the stomach in order to explain the cause of the 
asthma. This was already done by Boas. 



THE STOMACH IN OTHER DISEASES. 513 

Floating liver was noted in a considerable number (five) of 
these cases. There is hardly any doubt in my mind but that 
the abnormal position of the liver, dragging the diaphragm 
downward, is the cause of the existing dyspeptic asllmia in 
these cases. 

The treatment must be directed first toward relieving any 
existing disorders of the digestive tract; second, toward cor- 
recting any abnormal position of the abdominal organs, prin- 
cipally the liver. A regular mode of life, avoidance of too much 
tobacco and alcoholic drinks, also of too much mental worry 
and strain, is always of importance. By paying attention to 
these points the majority of cases of dyspeptic asthma will not 
only be temporarily relieved, but often radically cured. 

Diseases of the Liver. — Like affections of the heart, disturb- 
ances of the liver are also almost always accompanied by gastric 
symptoms, due to a hypersemic condition of the stomach. Thus 
in icterus and cirrhosis of the liver the stomach is the first to 
manifest various symptoms. Here, as in most other diseases, 
the secretory function of the stomach does not show any con- 
stancy; in some cases the gastric juice may be normal, in some 
increased, while in the greater number of cases it is diminished. 
In cirrhosis of the liver venectasias in the lower part of the 
oesophagus and cardiac portion of the stomach are occasionally 
observed, giving rise to hsematemesis. 

Diseases of the kidney are also frequently associated with 
gastric symptoms. Thus nausea and vomiting may be the 
first symptoms. They are caused either by excretion of urea 
through the gastric mucous membrane, or by the retention of 
that substance in the circulation and the irritation caused 
thereby upon the brain. Biernacki 1 has made a series of ex- 
aminations of the gastric condition in renal affections and 
found that in most of them the gastric secretion was greatly 

1 Biernacki: Berl. klin. Wochenschr., 1801, Xos. 25 and 20. 
33 



514 DISEASES OF THE STOMACH. 

diminished. Allen A. Jones 1 likewise frequently found aclrylia 
gastrica among patients with kidney troubles. Stone in the 
kidney may give rise to similar gastric disturbances. I have 
observed in a patient suffering from renal calculus, achylia 
gastrica which had existed for a long time, and given rise to 
many severe symptoms. After the removal of the stone by 
operation the gastric symptoms at once disappeared. 

The condition of the stomach in diabetes has been examined 
by Rosenstein 2 and Gans. 3 The gastric functions were found 
very variable. I have had the opportunity of examining quite 
a number of diabetics with regard to the gastric functions and 
must say that they do not show any constancy. Normal and 
abnormal conditions of secretion are alike found. 4 

In a case of chronic arthritis deformans and in two patients 
with severe gout I found achylia gastrica. In several instances 
in which only slight symptoms of gout existed, I frequently 
found hyperchlorhydria. 

The existence of gastric symptoms in malaria is well known, 
and Leube 5 first described several cases of very severe gastral- 
gia with absence of fever, which were due to malaria, as the 
successful treatment with quinine clearly proved. The malarial 
origin of the gastric symptoms will be apparent if they are 
intermittent and appear only at a certain time every day or 
every other day. I have observed several cases of obstinate 
vomiting due to malaria, but in most of these instances there 
have been, besides the gastric symptoms, other manifestations 
indicating the true nature of the condition. The gastric se- 



1 Allen A. Jones: "Gastric Conditions in Renal Disease," New York 
Medical Journal, January 19th, 1895. 

2 Rosenstein: Berl. klin. Wochenschr., 1890, No. 13. 

3 Edg. Gans: IX. Congress f. innere Medicin, 1890, Wiesbaden. 

4 Max Einhorn: "The Dietetic Treatment of Diabetes Mellitus." Journal 
American Medical Association., Dec. 29th, 1906. 

5 Leube: Deutsch. Arch. f. klin. Medicin, Bd. xxxiii. 



THE STOMACH IN OTHER DISEASES 515 

cretion here also does not show any characteristic feature, and 
is frequently diminished. 

Diseases of the Skin. — This subject, although of particular 
interest, has as yet received but very little attention. Pidoux 1 
considered all cases of dyspepsia due to a herpetic state of 
the system. The appearance of eczema, psoriasis, pityriasis, 
lichen, or acne in any case he considered as outward mani- 
festations of that constitutional anomaly which he called herpe- 
tisme. Nowadays no one will be inclined to accept this 
theory of a general constitutional anomaly for the origin of 
these troubles of the alimentary tract. Notwithstanding 
this there is no doubt that occasionally some connection is 
found between some skin manifestations and digestive dis- 
turbances. 

Pemphigus of the mouth has been described under the name 
of stomatitis neurotica chronica by A. Jacobi, 2 of New York. 
I observed tins affection present in three patients suffering from 
neurasthenia gastrica and hyperchlorhydria respectively. In 
two of these cases there was an improvement of the affection 
of the mouth (also tongue) in connection with the abatement 
of the gastric symptoms. In the third case, however, the 
pemphigus resisted every kind of treatment and persisted 
even during periods in which there were no complaints re- 
ferring to digestion. In this case there were frequently pres- 
ent a burning sensation within the oesophagus and slight symp- 
toms of dysphagia. Most probably they were also caused by 
the formation of vesicular patches along the oesophageal wall. 

Urticaria and erythema due to absorption in the digestive 

tract of some poisonous substances ingested with the food 

cially lobsters, soft-shell crabs, fish, and the like) are 



'Pidoux: 'Rapport de l'herp^tisme et des dyspepsies." [/Union me'di- 
cale, 1866, p. 235. 

A. Jacobi: Transactions of the Association of American Physicians, 
1894. 



510 DISEASES OF THE STOMACH. 

a\ -ell known and have been referred to above under the head 
of idiosyncrasies. 

With reference to eczema Hyde 1 says: a No one, however, 
can doubt for a moment that many visceral disorders have an 
influence upon the production of eczema, repeated attacks 
even following accesses of morbid affections of these organs; 
and it is equally certain that many varieties of eczema are 
directly dependent upon several systemic states such as, most 
effective in the list, gout and rheumatic gout, dyspepsia, con- 
stipation, and scrofula." Considering the large number of 
dyspeptics which come under my observation, I must say 
that the occurrence of eczema among them is very infrequent 
indeed. This would rather speak against an intimate con- 
nection between these two affections, although I have seen a 
case of eczema of the scrotum which had resisted the most 
rational methods of local treatment, in which the skin trouble 
very quickly disappeared after amelioration of the gastric 
symptoms. 

Acne simplex and acne rosacea seem to occur more frequently 
in connection with affections of the stomach than eczema. 
Two patients of mine with acne rosacea and chronic con- 
tinuous gastric succorrhcea have both shown a decided im- 
provement of the red nose after an amelioration of the gastric 
symptoms. In one of these patients I frequently noticed that 
the skin affection became worse as soon as there was an ex- 
acerbation of the gastric symptoms, but changed for the better 
upon improvement of the latter. 

In some cases of psoriasis, accompanied by digestive dis- 
orders, I did not observe that the improvement in the latter 
condition exerted any direct influence upon the skin affection. 

1 Hyde: "Twentieth Century Practice of Medicine," vol. v., p. 170. 



INDEX. 



Abbe. R., 146 

Abdomen, apparent tumors of. 201 
Abdominal bandages. 417 
Abelous, 99 

Abnormal constituents of gastric 
contents. 90 

sensations. IS 

of the stomach. 422. 439 
Abnormalities in the position of the 
stomach. 401 

in the shape of the stomach, 401 

in the size of the stomach, 400 
Abscess of stomach. 1SS 

subphrenic. 237 
Absorptive function of the stom- 
ach, 115 
Acetic acid, 71 
Achylia gastrica, 348 

course, 358 

definition, 348 

diagnosis. 359 

diet in. 153 

etiology, 351 

general remarks, 348 

morbid anatomy, 350 

prognosis. 359 

simulating hyperchlorhydria, 
354 

symptomatology, 352 

synonyms, 3 18 

treatment, 359 
Achroodextrin, test for. 70 
Acid -alt-, e-timation of. 73 
Acidity, determination of, 63 

gastric, approximate estima- 
tion of, 81 

Is, volatile, test for, 70 
rosacea, 516 

simplex. 516 
Adler, 94, 510 



Aerophagia, 467 

Akoria, 18, 426 

Albu, 395, 399 

Algesimeter, of Boas, 23 

Alizarin sodium sulphonate, 73 

Allotriophagia. 425 

Almen, 92 

Alt, 472, 473 

Anadenia ventriculi, 348 

Anakinesis, 116 

Anatomy of the stomach, 1 

Anderson, 230 

Andral, 505 

Anaemia, affecting the stomach, 509 

Angustatio ventriculi, 400 

Anorexia, 17 

nervous, 426 
Antiperistaltic restlessness of the 

stomach, 486 
Apparatus required, 181 
Appetite, 17 

perversion of, 425 
Aristoff, 506 
Armstrong, 265 
Arnold, 61, 289 

Arnold's test for lactic acid, 61 
Arnott, 155 

Arteries of the stomach. 6 
Arthritis deformans affecting the 

stomach, 514 
Aspirator, of Boas, 59 
Asthma, dyspeptic, 510 

dyspepl icum, 183, 510 
Atony of the stomach, 192 

definition, 192 

diagnosis, 192 

prognosis, 193 

symptomatology, 192 

synonyms, 192 

treatment, 193 



517 



518 



INDEX. 



Atrophy of the stomach, 348 
Auscultatory percussion, 26 

Baginski, 399 

Bandage, of G16nard, 417 

Bandages, abdominal, 417 

Bardet, 173 

Bardet's method, 172 

Barie, 510 

Barling, 262 

Bayliss, 12 

Beard, M., 170, 500 

Beaumetz, Dujardin, 395 

Beaumont, 9, 141, 183 

Beck, C, 238 

Belching, 18, 466 

Belt test, of Glenard, 411 

Benedict, 64 

Benedict's test for gastric acidity, 64 

Bentejac, 489 

Benzidin test, 94 

Berthold, 213 

Bettman, 66 

Bettman and Schroeder's method of 
testing for pepsin, 66 

Beverages, composition of, 131 

Bidder, 9 

Biernacki, 513 

Bile, 14, 90 

Billroth, 310 

Bird, Golding, 303 

Blondlot, 9 

Blood, 91 

test of Heller, 92 

test of Korczynski and Jawor- 

ski, 93 
test of Schonbein-Almen, 92 
tests for, 91 

Blood diseases affecting the stom- 
ach, 509 

Blood-vessels of the stomach, 3, 6 

Blutin, 155 

Boas, 23, 24, 25, 53, 56, 58, 59, 60, 
62, 72, 92, 93, 96, 97, 99, 108, 163, 
21).-,, 303, 304, 317, 318, 332, 346, 
349, 351, 362, 363, 364, 395, 420, 
429, 450, 473, 479, 492, 493, 510 



Boas's algesimeter, 23 
aspirator, 59 
resorcin sugar test, 60 
test for lactic acid, 62 
Bocci, 169, 172 
Bouchard, 26 
Bourneville, 472 

Bouveret, 330, 338, 345, 351, 395, 
396, 399, 426, 467, 479, 491, 497 
Bra, 281 

Brady phagia, 139 
Brieger, 16, 399, 503 
Brinton, W., 194, 212, 224, 228, 
234, 238, 276, 278, 280, 284, 285, 
286, 287, 289, 290, 295 
Brock, 179 
Brunton, L., 14 
Bryant, Joseph, D., 276, 277 
Bubbling sounds, 28 
Bulimia, 18, 423 
cause, 424 

symptomatology, 423 
treatment, 424 
Bull, 146 
Burkhart, 497 
Bush, 155 

Cahn, 302, 486 

Cancer of the pylorus, 375 

Cancer of the stomach, 276 

definition, 276 

diagnosis, 302 

differential diagnosis, 241, 306 

duration and prognosis, 309 

etiology, 276 

hydrochloric acid in, 302 

lactic acid in, 303 

localization, 284 

metastasis, 286, 295 

morbid anatomy, 281 

palliative operations for, 310 

parasitic theory, 281 

radical operations for, 310 

radium treatment, 312 

secondary changes accompany- 
ing, 286 

shape of the stomach in, 285 



INDEX. 



519 



Cancer of the stomach, symptomat- 
ology, 2S7 

topographical relations ot 2S4 

treatment. 309 

varieties. 2S2 
Cannon. 13 
Canstatt. 172 
Cantarono. G., 472 
Carcinoma ventriculi, 276 
Cardiac glands, 5 
Cardialgia. 442 

Cardiodilator. of Einhorn, 461 
Cardiospasmus, 450 
Catarrhus ventriculi acutus, 1S2 
Cazenave, 36 
Cells, Xussbaum, 5 

oxyntic, 5 

parietal, 5 

snail-like, 97 

yeast, 100 
Cereals, composition of, 131 
Charcot, 428, 429, 443 
Chemicals required, 181 
''Chewing the cud," 470 
Chiari, 258. 505 

Chlorosis affecting the stomach, 539 
Chossat, 431 
Chvostek, 396 
Chyle, 16 
Chyme, 13 

determination of quantity of, 83 
Cirrhosis ventriculi, 194 
Clapotage, 26 
Cloquet, 280 
Cohnheim, 256, 384 
Cole, 43, 46, 391 
Coley, 281 
Condition of the stomach in diseases 

of other organs, 502 
Contra-indications to use of stom- 
ach tube, 78 
Cornil. 505 

; stigma, 404 
Croner, 62 
Cronheim, 62 

Cruveilhier, 143. 212. 227, 245 
Cynorexia, 423 



Daettvyler. 214 

Dairy products, composition of, 129 

De Bary, 99 

Debove. 27, 224, 237, 244. 2 Hi. 27S, 

338, 5(14 
Deglutible stomach electrode of 

Einhorn, 174 
Deglutition, 18 

sounds, 27 
Dehio, 24 
Dejerine, 444 
Demange, 444 
Descensus ventriculi, 402 
Devic, 395, 396, 399 
Dextrin, test for, 70 
Diabetes affecting the stomach, 514 
Diaphane, pyloric dilator and, 387 
Dickinson, 83 
Diet, 127 

in health, 137 
Diet list of Einhorn, 142 

of Leube, 141 

of von Xoorden, 148 
Dietetics, 127 

in acute diseases of the stomach, 
143 

in chronic affections of the 
stomach, 145 

in diseases of the stomach, 139 
Dieulafoy, 258, 506 
Dieulafoy's exulceratio simplex, 258 
Digestibility, scale of, 142 
Digestion, 7 

gastric, 11 

intestinal, 14 

starch, products of, 69 
Digestive juice aspirator of Ein- 
horn, 86 
Dilatation of the cardia, 160 

of the oesophagus, 152. 157, 162 

of the stomach, 362 
Dilated stomach, 100 
Dilator, pyloric, and diaphane, 387 
Dimethylamido-azobenzol, 72. 82 
Dittrich, 239 
Dobson, 262 

Douche. L r .i-trie, 160 



520 



INDEX. 



Dripping sounds, 28 
Duchenne, 172 
Dunham, 84, 104 
Dunham's thread test, 84 
Duodena] bucket, of Einhorn, 245 

feeding apparatus, of Einhorn, 
252 

pump, of Einhorn, 85, 86 
Dyspepsia, nervous, 495 
Dyspeptic asthma, 483, 510 

Eating, hints in regard to, 137 
Ebstein, 486 
Ectasia ventriculi, 362 
Eczema, 516 
Edinger, 79, 503 
Ehrlich, 510 
Eichhorst, 280 

Einhorn's apparatus for pepsin 
determination, 67 

bandage for enteroptosis, 418 

cardiodilator, 461 

deglutible electrode, 174 

diet, in gastric ulcer, 247 

diet list, 142 

diet list, for chronic gastric 
catarrh, 202 

digestive juice aspirator, 86 

disease, 268 

divisible oesophageal bougie, 
298 

duodenal bucket, 245 

doudenal feeding apparatus, 
252 

duodenal pump, 85, 86 

gastric douche, 161, 162 

gastric powder-blower, 166 

gastric spray-apparatus, 164 

gastrodiaphane, 37 

gastrograph, 120 

gastroscope, 35 

method for pepsin determina- 
tion, 67 

method of direct electrization, 
174 

oesophageal drainage tube, 459 

cesophagoscope, 31 



Einhorn's pyloric dilator and aspira- 
tor, 386, 388 

radiodiaphane, 49 

radium applicators, 314, 315, 
316 

radium introducer, 316 

radium receptacles, 313, 314 

stomach-bucket, 79 
Eisenlohr, 296 
Electricity, 168 
Electrization, direct, of stomach, 171 

method of Bardet, 172 

method of Einhorn, 174 

method of Kussmaul, 172 
Electrode, deglutible, of Einhorn, 

174 
Elsberg, 110 
Eisner, 35 
Emmerich, 281 
Enemata, nutritive, 144 
Enterokinase, 12 
Enteroptosis, 402 

definition, 402 

diagnosis, 410 

etiology, 403 

general remarks, 402 

prognosis, 411 

symptomatology, 405 

treatment, 412 
Eppinger, 504 
Erb, 171, 396 
Erosions of the stomach, 267 

condition of gastric juice in, 
271 

course, 271 

definition, 267 

diagnosis, 273 

etiology, 268 

general remarks, 267 

symptomatology, 268 

treatment, 273 
Eructation, 466 

etiology, 468 

treatment, 468 
Erythema, 515 
Erythrodextrin, test for, 70 
Euphagia, 137 



IXDEX. 



521 



Ewald. C. A., 15, 37, 53, 56, 58, 73, 
101, 117, US, 139, 155, 170, 179, 
180, 192, 193, 207, 209. 213, 214, 
215. 218, 219, 257, 267. 2S0, 286, 
294. 302. 31S, 319, 320. 321, 342, 
349. 350. 351. 365. 395. 399. 400, 
40S. 422. 424. 444. 456. 474. 495, 
509 
Ewald. R.. 422 

Ewald's diet list for chronic gastric 
catarrh. 202 
stomach tube, 58 
Ewald and Boas, expression method 
of, 58 
test breakfast of, 56 
Ewald and Einhorn, method of 
testing motor functions of the 
stomach. 117 
Ewald and Sievers' method of 
testing the motor function of the 
stomach, 117 
Examination, methods of. 17, 20 
microscopical, of gastric con- 
tents, 97, 98 
of gastric contents, value and 

limitations of, 113 
of the ingesta, 59 
physical, 20 
Exploratory laparotomy. 312 
Expression method of Ewald and 

Boas, 58 
Exulceratio simplex, Dieulafov, 

258 
Exulceratio simplex ventriculi, 258 
definition, 259 
diagnosis, 260 
etiology, 260 
morbid anatomy, 250 
prognosis, 261 
symptomatology, 260 
treatment, 261 

Faber. 115 

I'jf--. examination of, for occult 

blood, 93 
la-tin:: condition, examination of 

stomach in, 119 



Fat-splitting ferment, 10 
Fenwick, S., 349 
Fenwick, W., 503 
Ferments. 7, 8 
Fischer, 304 

Fish, composition of, 130 
Fleiner, 255, 395, 398 
Fleischer, 61 
Flexner, 506 
Floating liver, 409 

symptoms of. 409 
Food, composition of, 129 

enemata. 144 

fear of, 430 

utilization of. 137 
Foods, animal, 133 

liquid, 136 

vegetable, 135 
Foote, 262 
Forster, 127, 246 
Fournier, 506 
Fox, 218, 246. 278 
Fraenkel, 364, 506 
Frerichs, 25 
Friedenwald, 37, 72 
Friedlieb, 158 
Friedlieb's apparatus for lavage 1 , 

158 
Friedreich, 317 
Fruits, composition of, 132 
Fubini, 169 
Fuerstner, 170, 171 
Fuld, 64 

Functions of stomach, absorptive, 
115 

examination of. 53 

mechanical, 119 

motor, 116 

secretory, 53 
Fundus glands, 5 

Funnel arrangement for gastric 
lavage, 155 

Gaill4BD, 505 
( lame, composition of. 130 
Gans, 514 
ner, 395 



522 



INDEX. 



Gastralgia, 19, 442 

central, 443 

constitutional, 445 

diagnosis, 446 

etiology, 443 

nervous, differential diagnosis, 
241 

neurotic, 444 

reflex, 445 

stomachic, 443 

symptomatology, 442 

synonyms, 442 

treatment, 449 
Gastralgokenosis (Boas), 453 
Gastric acidity, Benedict's test for, 

64 
Gastric catarrh, acute, 182 

diet in, 143 
Gastric catarrh, chronic, 191 

course, 200 

definition, 191 

diagnosis, 200 

differential diagnosis, 230 

etiology, 194 

pathological anatomy, 191 

prognosis, 201 

symptomatology, 195 

treatment, 202 
Gastric contents, abnormal con- 
stituents of, 90 

microscopical examination of, 
97, 98 

value and limits of examina- 
tion of, 113 
Gastric digestion, 11 
Gastric douche, 160 

of Einhorn, 161, 162 

of Malbranc, 160 
Gastric idiosyncrasies, 437 
Gastric insufficiency, 362, 432 
Gastric juice, constituents of, 10 

continuous flow of, chronic, 
337 

periodic, 331 

physiology of, 9 

secretion of, 10, 11 

snail-like cells in, 97 



Gastric mucosa, atrophy of, 348 

pathological histology of, 103 

pieces of, found in 
wash-water, 107 
Gastric neuroses, motor, 450 

secretory, 494 

sensory, 421 
Gastric pneumatosis, 483 
Gastric secretion, 10, 11 

different methods of testing, 78 
Gastric spray, 164 

apparatus of Einhorn, 164 
Gastric ulcer, 212 

condition of the gastric con- 
tents in, 232 
Gastritis acuta simplex, 182 

diagnosis, 185 

etiology, 182 

morbid anatomy, 183 

prognosis, 186 

symptomatology, 184 

treatment, 186 
Gastritis, acute, 182 

definition, 182 

synonyms, 182 
Gastritis chronica mucosa, 198 
Gastritis glandularis acuta, 182 
Gastritis glandularis chronica, 191, 

351 
Gastritis phlegmonosa, 187 

diagnosis, 189 

morbid anatomy, 188 

symptomatology, 188 

synonyms, 187 

treatment, 189 
Gastritis phlegmonosa purulenta,187 
Gastritis toxica, 189 

diagnosis, 190 

prognosis, 190 

symptomatology, 189 

treatment, 190 
Gistrodiaphane, Einhorn's 37 
Gastrodiaphany, 36 
Gastrodynia, 442 
Gastroenterostomy, 311 
Gastro-faradization, 175 
Gastro-galvanization, 176 



IXDEX. 



523 



Gastrograph, 120 

of Einhorn, 120 
Gastrogranis, 12-4 
Gastrokinesograph, 122 
Gastroptosis, 402, 407 
Gastroscope, of Einhorn, 35 
Gastroscopy, 33 
Gastrospasnius. 442 
Gastrostomy, 311 

Gastrosuccorrhoea continua chro- 
nica, 337 

definition, 337 

diagnosis, 340 

differential diagnosis, 341 

etiology, 339 

general remarks, 338 

prognosis, 344 

symtomatology, 339 

synonyms. 337 

treatment, 345 
Gastrosuccorrhoea continua peri- 
odica, 331 

definition, 332 

diagnosis, 336 

general remarks, 332 

prognosis, 336 

symptomatology, 332 

synonyms, 331 

treatment, 336 
Gastroxynsis (Rossbach), 331 
Gerhardt, 267, 395, 399 
Gerster, 146 
Glands of the stomach, 4 

cardiac, 5 

fundus, 5 

mucous, 5 

pyloric, 5 
Glax, 486 
Glenard, F., 402 

bandage of, 417 

belt test of, 411 
Glenard'- di-oase, 402 
Gliicksmann, 265 
Glusinsky, 232, 320 
Gold.schmidt, 179 
Goodsir, 101 
Got t stein, 30, 460 



Gout, affecting the stomach, 514 
Gries, 213 
Griesinger, 277 
Griffin, 214 
Gross, 161 
Gruber, 127 
Grundzach, 349 
Gull, 428 
Gunzburg, 60, 78 

Giinzburg's method of testing gastric 
secretion, 78 
phloroglucin- vanillin test, 60 
Gurgling sounds, 29 
Gyromele of Turck, 180 

Hacker, von, 30 

Haeberlin, 276, 277, 279, 296 

Haemin test of Teichman, 93 

Haller, 401 

Hampeln, 294 

Hanot, 395 

Harada, 170 

Harttung, 217, 267 

Hauser, 280 

Hayem, 9, 75, 77, 509 

Hayem and "Winter, method of, 75 

Heartburn, 468 

Heart diseases affecting the stomach, 

509 
Heat units, 128 
Heat- value of foods, 128 
Hehner, 75, 77 

Hehner and Seemann, method of, 75 
Heichelheim, 118 
Heidenhain, 5 
Heim, 399 
Heincke, 146 
Heinemann, 277 
Heller, 92 

Heller's blood test. 92 
Hemmeter, 124, L25, 126, L59, 195, 

506 
Hemmeter-Morilz's method, 12 1 
Henderson, 411 
Henoch, 483, 510 
Henry, 349 
Hepatoptosis, 109 



524 



INDEX. 



Herschell, 115 
Herschell's method, 115 
Heryng, 37 

Heterochylia (Hemmeter), 405 

Hildebrandt, 503 

Hippocrates, 29, 154 

Hirschfeld, 132 

Hoffmann, 127, 170 

Hoist, 94 

Holzknecht, 40 

Honigmann, 76, 77 

Honigmann and von Noorden's 

method, 76 
Hour-glass stomach, 401 
Howell, 16 
Hubbard, 473 
Huber, 118 

Huber's modification, 118 
Huefler, 510 
Huhnerfeld, 92 
Hulst, 40 
Hunter, 364 
Hyde, 516 
Hydrochloric acid, 10 

free, estimation of, 71 

combined, estimation of, 73 

deficit, determination of, 76 

methods for estimation of, 75 

tests for, 59 
Hypanakinesis ventriculi, 484 
Hyperacidity, 320 
Hyperesthesia of the stomach, 439 

diagnosis, 440 

symptomatology, 440 

treatment, 441 
Hyperanakinesis ventriculi, 484 
Hyperchlorhydria, 320 

course, 324 

definition, 320 

diagnosis, 336 

differential diagnosis, 241, 327 

etiology, 322 

general remarks, 320 

prognosis, 326 

symptomatology, 322 

synonyms, 320 

treatment, 327 



Hyperorexia, 423 
Hypersecretion, 320 

Idiopathic nervous vomiting, 482 
Idiosyncrasies, gastric, 437 
Immermann, 503 
Inanition, 431 
Incontinentia pylori, 486 
Inflation of stomach, 25 
Ingesta, examination of the, 59 
Inspection, 20 
Instruments required, 180 
Interrogation of the patient, 17 
Intestinal digestion, 14 

juice, 90 
Iodopin test, 118 
Ischochymia, 362 

acute, 364 

chronic, 366 

complications, 394 

constant, 365 

course, 366 

definition, 362 

diagnosis, 378 

differential diagnosis, 379 

etiology, 366 

general remarks, 362 

symptomatology, 364 

synonyms, 362 

transient, 364 

treatment, 382 
Israel, 408 

Jackson, 33 

Jacobi, 515 

Jacobsohn, 37, 399 

Jakoby, 66, 67 

Jakoby and Solnjs' method of testing 

for pepsin, 66 
Jaworski, 93, 97, 208, 218, 232, 320, 

349, 471, 476 
Johannessen, 471, 476 
Jones, 179, 350, 514 
Juergensen, 474, 476 
Juvenile vomiting, 479 

Kahlbaum, 48 



INDEX. 



525 



Kahler, 444 
Hammerer, 375 

Katzenellenbogen. 285. 2S9 
Kaufmann, 99, 100, 232 
Kelling, 30, 3S2 

Kemp, 39, 509 
Key, 217 

Kidney disease affecting the stom- 
ach, 514 
movable, 409 

symptoms of, 409 
Kinnicutt, 349 
Kirkpatrick. 265 

Klemperer, 57, 119, 296, 304, 503 
Klemperer's oil test, 119 

test meal, 57 
Klung?. 94 
Koch. 214 
Koenig. 12S, 152 
Koemer. 471, 476 
Korczynski. 93, 218 
Korczynski and Jaworski, blood 

test of. 93 
Kronecker. 27 
Kuhn, 366 
Kulneff. 399 
Kupffer, 5 
Kussmaul, 155, 171, 172, 395, 393, 

4S4 
Ku— maul*s method, 172 
•<>mach pump, 156 
Kuttner, 37 

3LAACHE, 296 

Lactic acid. 60. 70 

estimation of. 71 

test of Arnold, 61 
• of Boas, 62 

test of Uffelmann, 60 

tr-r of Yournasos, 62 
Laker, 30 
Lambert, 250 
Lancereaux, 505 
Landau. 402 
Landf-rf-r. 265 
Landouzy. 4 14 
Lange, 146. 373, 378 



Langsrhans, 217, 267 

Laporte, 68 

Laiienstein, 265 

Lauterbach, 510 

Lavage, 155 

contraindications to, 160 
Lriedlieb's apparatus, 158 
funnel arrangement for. 155 
indications for, 160 
Leube-Rosenthal's apparatus, 

156, 157 
rules for application of, 1 50 
with tube a double courant, 159 

Lebert, 183, 276, 278, 279. 285, 286 

Lehman, 431 

Lehnhartz's diet in gastric ulcer, 
249 

Lente, 170 

Leo, 73, 74, 424 

Leo's method, 73 

Leube, 55, 116, 139, 141, 170, 207, 
231, 246, 251, 402, 495, 514 

Leube's diet list, 141 

Leube's method, 116 

Leube-Riegel's test dinner. ^~-> 

Leube-Rosenthal apparatus for lav- 
age, 156, 157 

Leube-Ziemssen's rest cure, 246 

Leubuscher, 170, 345 

Leven, 395, 497 

Levy, 179 

Lewy, 349 

Ley, 305 

Leyden, E. von, 237, 444, 478, 479, 
504 

Litten, 350, 504 

Liver, 14 

diseases affecting the stomach, 

513 
floating, 409 

Loeb, 399 

Loven, 8 

Lubarsch, 350 

Luciani. 431 

Ludwig, 169 

Luettl 

Lymphatics of the stomach, 6 



526 



[NDEX. 



M \< ]• LDYEN, 99 

Mackay, 506 

Malacia, 1'-'.") 

.Malaria affecting the stomach, 514 

Malbranc, 160, 500 

Malbranc's gastric douche, 160 

Maltose, test for, 70 

Maly. 10 

Manges, 37 

Marcet, 215 

Markoe, 265 

Martins, 37, 77, 339, 350 

Mathieu, 89, 278 

Maybaum, 452 

Mayo, 146 

McBurney, 146 

McCosh, 265 

Meals, test, 55, 57 

Meat powder, 360 

Meats, composition of, 130 

Mechanical function of stomach, 119 

insufficiency of stomach, 363 
Megastria, 400 
Meltzer, 27, 452 
Meltzing, 37 
Menetrier, 280 
Mering, von, 302 
Merycism, 470 
Methods of examination, 17 
Mett, 65 
Mett's method of testing for pepsin, 

65 
Meyer, E., 96 
Meyer, George, 349 
Meyer, Willy, 146, 373, 374 
Micro-organisms in the stomach, 100 
Mikulicz, 30, 33, 146 
Milk test, 88 
Miller, 99 
Milliot, 36 
Minkowski, 100 
Mintz, 71, 268 
Mintz's method, 71 
Mitchell, Weir, 153, 429, 500 
Moerner, 72 

Moerner and Boas, method of, 72 
Morgan, W. Gerry, 152, 254 



Moritz, 124, 125 

Motor function of the stomach, 116 

insufficiency of stomach, 362 

neuroses, 450 
Mould, in the stomach, 101 

significance of, 106 
Movable kidney, 409 
Movements of the stomach, 13 
Mracek, 506 
Mucous glands, 5 
Mucus, 90 

Muller, F., 296,395, 398 
Munk, 128, 134 
Murchison, 258 
Murdoch, 511 
Murphy, 146 
Musser, 504 
Myasthenia ventriculi, 492 

Naunyn, 101 

Nausea, 19 

Nauwerk, 268 

Neftel, 170 

Nencki, 99 

Nephroptosis, 409 

Nerves of the stomach, 6, 7 

Nervous affections of the stomach, 

420 
Nervous anorexia, 426 

diagnosis, 428 

symptomatology, 427 

treatment, 428 
Nervous dyspepsia, 495 

definition, 495 

diagnosis, 498 

differential diagnosis, 499 

etiology, 496 

prognosis, 498 

symptomatology, 496 

treatment, 500 
Nervous gastralgia, differential diag- 

nois, 241 
Nervous vomiting, 477 

diagnosis, 478 

idiopathic, 482 

juvenile, 479 

periodic, 479 



INDEX. 



527 



Nervous vomiting, reflex. 4SI 
treatment, 4S0, 481, 4s_' 

Neubauer, 304 

Neumann, 395 

Neurasthenia gastrica, 495 

Neuroses, motor, 450 
secretory, 494 
sensory, 421 

Nolte, 213, 224 

Noorden, von, 76, 77, 129, 139, 148, 
432. 444 

Noorden, von, diet list of, 148 

Nothnagel, 349 

Occult blood, examination of faaces 

for, 93 
(Esophageal bougie, divisible, of 

Einhorn, 298 
(Esophageal drainage tube, Ein- 

horn's, 459 
(Esophagoscope, Einhorn'-. 31 
(Esophagoscopy, 30 
(Esophagus, dilatation of, 452, 402 

diagnosis of, 457 
Oka, 170 
Oppenheim, 444 
Oppler, 510 

183, 309, 444 
Osier, 21, 349, 506 

Pacanowski, 493 

Pains, 19 
Paliard, 399 
Palpation, 22 

with pressure, 23 
Pancreatic juice, 15 
Panum, 218 
Pariser, 37, 268 
Park, Roswell, 146 
Parker, 205 
Parorexia, 17, 425 
Pavy, 218 

Pawlow, 10, 11, 12, 138 
Peiper, 504 

Pemphigus of the mouth, 515 
Penzoldt, 21. 115. 133. 1 11 
Penzoldt and Faber'g method, 115 



Pepper, W., 26, 171 

Pepsin, 10 

tests for, 05 
Peptone, test for, 65 
Percussion, 24 

auscultatory, 26 
Percy, 426 

Periodic vomiting (Leyden), 17;) 
Peristaltic restlessness of the stom- 
ach, 22 

(Kussmaul), 484 
Pettenkofer, 127 
Peyer, 424 
Pfuhl, 237 

Phenolphthalien test for blood, 98 
Phloroglucin-vanillin test, of Giinz- 

burg, 60 
Photographs, radium, 50, 391 
Phthisis ventriculi, 348 
Physical examination, methods of, 20 
Physiology of the stomach, 1, 7 
Pica, 425 
Pidoux, 515 
Piorry, 24 
Plummer, 460 
Pneumatosis, gastric, 483 
Polyphagia, 18, 426 
Ponsgen, 477 
Powder-blower, gastric, of Einhorn, 

166 
Prochoresis, 110 
Propeptone, test for, 65 
Prout, 9 
Psoriasis, 510 
Psychical secretion, 12 
Ptyalin, 8 
Pus, 90 
Pyloric dilator and aspirator, of 

Einhorn, 386, 388 
Pyloric dilator and diaplnme. 387 
Pyloric glands, 5 
Pylorospasmus, 188 
Pylorus, benign stenosis of, 370 

cancer of. 301 . 375 

incontinence of, ISO 

malignant stenosis of, 375 

:io-i- of, 362 



528 



INDEX. 



Pylorus, syphilitic stenosis of, 508 
Pyrosis, 18, 468 

Quincke, 214 

Quintard, 268 

Padiodiaphane, Einhorn's, 49 
Radium, applicators, of Einhorn, 
314, 315, 316 

introducer, of Einhorn, 316 

photographs of the oesophagus, 
463 

photographs of the stomach, 50, 
391 

receptacles, of Einhorn, 313, 314 

transillumination of the 
stomach, 48 

treatment for cancer, 312 
Rave, 179 
Reaumur, 9 
Reflex vomiting, 481 
Regurgitation, 18, 468 

etiology, 470 

prognosis, 470 

treatment, 470 
Reibmayr, 415 
Reichmann, 37, 320, 331, 332, 337, 

338, 342, 346 
Reichmann's disease, 337 
Remond, 27, 89, 224, 237, 244, 246, 

338 
Rennet, 10 

test for, 69 
Renvers, 37, 395, 446 
Resorcin sugar test of Boas, 60 
Respiratory sounds, 29 
Richet, 494 
Richter, 170, 497 
Rieder, 40 
Riegel, 55, 218, 232, 320, 338, 339, 

346 
Rindfleisch, 217 
Ringing sounds, 30 
Rockwell, 170, 500 
Roentgen rays, 40 

Roentgenography of the stomach, 40 
Rokitansky, 217 



Rose, 216, 418 

Rosenbach, 28, 331, 332, 362, 

492 
Rosenbloom, 297 

Rosenheim, 30, 34, 77, 160, 163, 179, 
223, 239, 255, 280, 304, 318, 349, 
382, 440, 441, 460, 500, 509 
Rosenstein, 514 
Rosenthal, 421, 422, 425, 426, 427, 

428, 503 
Rossbach, 332 
Rumination, 18, 470 

chemical analysis, 472 
definition, 470 
duration, 472 
etiology, 471 
synonyms, 470 
treatment, 476 
Runeberg, 25 

Sachs, 5, 184 
Sahli, 79 
Saliva, 8 
Salkowski, 296 
Salol test, 117 
Samuel, 431 
Sansoni, 268 
Sarcinae ventriculi, 100 
Sawjalow, 10 
Schaeffer, 345 
Schetty, 503 
Scheuerlen, 281 
Schillbach, 169 
Schlesinger, 94, 399 
Schmidt, 9 
Schneider, 293 
Schneyer, 296 
Schonbein, 92 

Schonbein-AlmeVs blood test, 92 
Schreiber, 339 
Schroeder, 66 
Schultz, 486 
Schwann, 9 

Sclerosis ventriculi, 194 
Secretin, 12 
Secretory function, 53 
neuroses, 494 



INDEX. 



529 



See. Germain. 56, 39S 

test meal of, 56 
Seemann. 75. 77 
Seglas, 472 
Semmola, 170 
Senn, X., 146 
Sensations, abnormal, 422. 439 

special, within the stomach, 436 
Sensory gastric neuroses. 421 
Sere. L. de, 486 
Siegheim, 509 
Sievers, 117 
Silbermann, 214. 510 
Sippey, 460 
Sitieirgy, 427 
Sitophobia, 430 
Situation of the stomach, 2 
Sizzling sounds. 29 
Sjoequist. 73. 77 
Skin diseases, affecting the stomach, 

515 
Snail-like cells in gastric juice, 97 
Snow, 279 
Sodium hydrate standard solution, 

64 
Sohlern, von, 213 
Sollier, 427 
Solms, 66, 67 
Sommerville, 155 
Sounds, bubbling, 28 

deglutition, 27 

dripping, 28 

gurgling, 29 

of the stomach, 26 

respirator}-, 29 

ringing, 30 

-izzling, 29 

splashing, 26 

succussion, 28 
Soups, composition of, 131 
Spallanzani, 9, 79 

Spallanzani and Edinger's method, 79 
Spasm of the cardia, 450 

diagnosis, 457 

prognosis, 158 

symptomatology, 151 

treatment, 458 



Splashing sound. 26 

Spray, apparatus, gastric, of Ein- 

horn, 164 
Starch digestion, products of, 69 

tests for, 69 
Stark, 213 
Starling, 12 
Stenosis of the pylorus, 362 

benign, 370 

cancerous, 375 

malignant, 375 

syphilitic, 508 
Stern, 510 
Steven, 259 
Stewart, 37, 179, 350 
Stiller, 403, 478 
Stimson, 265 
Stinzing, 133 

Stockton, 37, 173, 178, 179, 218, 495 
Stoehr, 5 
Stolper, 505 

Stomach, abnormalities in position 
of, 401 
in shape of, 401 
in size of, 400 

abscess of, 188 

absorptive function of, 115 

anatomy of, 1 

antiperistaltic restlessness of, 
486 

arteries of, 6 

atony of, 492 

atrophy of, 348 

blood-vessels of, 3, 6 

bucket of Einhorn, 79, 

cancer of, 276 

condition of, in other diseases, 
502 

cow-horn, 53 

dilatation of, 362 

dilated, 400 

drain-trap. 13 

electrization of, direct .171 
method of Einhorn, 1 7 I 

electrode, deglutible, of Ian- 
horn. 171 

erosions of, 2o7 



530 



[NDEX. 



Stomach, examination of, in the 
fasting condition, 119 
fish-hook, 42 
glands of, 4 
hour-glass form, 401 
hyperesthesia of, 439 
in anaemia, 509 

arthritis deformans, 514 

chlorosis, 509 

diabetes, 514 

diseases of the blood, 509 
of the kidney, 514 
of the liver, 513 
of the skin, 515 

dyspeptic asthma, 510 

gout, 514 

heart lesions, 509 

malaria, 514 

pulmonary tuberculosis, 
502 

syphilis, 505 
inflation of, 25 
lavage of, 155 
local treatment of, 155 
low position of, 402 
lymphatics of, 6 
mechanical function of, 119 
methods of examination of, 17 

of inflation of, 25 
micro-organisms in, 100 
motor function of, 116 
movements of, 13 
mucous membrane of, 3 
muscular coat of, 3 
nerves of, 6, 7 
nervous affections of, 420 
peristaltic restlessness of, 22, 

484 
physiology of, 1, 7 
pump of Kussmaul, 156 
purulent inflammation of, 187 
radium photographs of, 50, 391 

transillumination of, 48 
relations to neighboring organs, 3 
roentgenography of, 40 
secretory functions of, 53 
serous coat of, 3 



Stomach, situation of, 2 

sounds of, 26 

structure of, 3 

submucous coat of, 3 

superficial ulceration of ,258 

syphilis of, 505 

text-book, 42 

transillumination of, 36 
by radium, 48 

transposition of, 401 

tube, contraindications to use 
of, 78 
Ewald's, 58 

ulcer of, 212 

veins of, 6 

vertical position of, 401 

volume of, 2 
Stomatitis necrotica chronica, 515 
Strauss, H., 77, 381 
Structure of the stomach, 3 
Subnutrition, 432 
Subphrenic abscess, 237 
Succussion sound, 28 
Surgical procedures in gastric ulcer, 

262 
Syphilis of stomach, 505 

Tachyphagia, 138 
Talma, 101, 438 
Tanaka, 79 
Taste, 18 
Teichmann, 93 
Teichmann's hsemin tests 93 
Test breakfast, 56 

dinner, 55 

meals, 55, 57 

of Ewald and Boas, 56 
of Leube-Riegel, 55 
of Germain See, 56 
Tests for hydrochloric acid, 59 
Tetany, 394 
Thayer, 304 
Thirst, 18 

Thomas' guage, 389 
Thompson, W. G., 145 
Thread test of Dunham, 84 
Toepfer, 72, 73 



INDEX. 



:y.]i 



Toepfer's method, 72 

Tormina ventriculi nervosa, 4S4 

Transillumination of the stomach, 36 

radium, 48 
Transposition of stomach, 401 
Trastour, 405 

Treatment, local, of the stomach, 155 
Trousseau. 312, 395, 396 
Tschelzoff, 20S 
Tuberculosis of the lungs, stomach 

in, 502 
Tumor, apparent, of abdomen, 291 

particles of, in gastric contents, 
112 

syphilitic of stomach, 507 
Torek, F. B.. ISO, 214 
Turck's gyromele, 180 

Uffelmaxx, 60, 128, 154 
Uffelmann's test, 60 
Ulcer, gastric, of syphilitic origin, 506 
Ulcer of the stomach, 212 

complications, 234 

definition, 212 

diagnosis, 239 

diet in, 143 

differential diagnosis, 240 

duration, 234 

etiology, 212 

latent, 233 

localization, 242 

morbid anatomy, 220 

multiple, 224 

perforation, 234 

prognosis, 244 

progress, 225 

situation, 224 

surgical treatment. 262 

symptomatology, 226 

synonyms, 212 

syphilitic, 506 

treatment 245 
UK-oration, superficial of the stom- 
ach, 258 
Ulcus pepticum, 212 

rodens, 212 

-implex, 212 



Ulcus ventriculi perforans, 212 

rotundum. 212 
Urticaria, 515 

Van den Veldex, 302 

Vassale, 214 

Vegetables, composition of, 131 

Veins of stomach, 6 

Verbycke, 254 

Vierordt, 132 

Virchow, R., 127, 217, 267, 276, 402 

Voinovitch, 345 

Voit, 127 

Volatile acids test for, 70 

Volhard, 10 

Vomiting, 19, 

idiopathic nervous, 482 

juvenile, 479 

nervous, 477 

periodic, 479 

reflex, 481 
Vomitus nervosus, 477 
Vournasos, 62 
Vournasos' test for lactic acid, 62 

Wagner, 249, 505 

Waldeyer, 281 

Weber, 92, 169 

Wegele, 180 

Weir, Robert F., 146, 262, 265 

Welch, 224, 278, 285 

Wells, 179 

Weiderhoefer, 278 

Wilkinson, 278 

Williams, 40 

Willigk, 276 

Winter, 9, 75, 77 

Witzel, 311 

Wolff, 345, 349 

Wyss, 276 

X-Rays, 40 

Yeast cells, LOO 

ZlEMSSEN, vox. 169. 173, 246, 251, 

100. 
Zuntz. 131 



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One copy del. to Cat. Div. 






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